
Class XM-I*lL 
Book W I f . _ 

Copyright N°_ 



COPYRIGHT DEPOSIT. 



A Text Book 

OF 



Alkaloidal Practice 



This new "Treatment of the Sick," with especial refer- 
ence to the use of the active principles and other posi- 
tive definite medicaments, not only contains the living 
essentials of Dr. Waugh's old book, whatever has 
stood the test of time and progress, but the very latest 
(practically all the rich store) in modern medicine. It is 
a dependable, every-day help that you will appreciate. 



BY 



WILLIAM F. WAUGH, M. D. 
WALLACE C. ABBOTT, M. D. 



CHICAGO 

THE CLINIC PUBLISHING CO. 

1907 



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COPYRIGHT 



THE CLINIC PUBLISHING CO. 
1907 



^"NOTE- The right to use any of this 
material in other than book form, and with 
due credit, is freely accorded to those who 
desire to disseminate these truths. 



PREFAC E 



In the preparation of this book, in addition to their own personal 
experience, its authors have availed themselves of the best material 
at their disposal, taking what they believed to be good from every 
source. It is impossible to acknowledge each of these separately, or 
to trace to its original source every bit of information presented; nor 
would it add to the value of the work in the least, though largely 
increasing the labor. And time is too short and art too long to admit 
of useless or unfruitful work. But especially do the authors desire 
to acknowledge their indebtedness to Osier's and Anders' text-books, 
Babcock on the Heart, NothnageFs Encyclopedia, Pearce on Nervous 
Diseases, Manson on Tropical Diseases, whose lucid descriptions and up- 
to-date pathology have been freely drawn upon throughout. But as we 
have not hesitated to take material from other sources, and to modify 
in accordance with our own views, it must be understood that no respon- 
sibility is to be attributed to these or other authors for any statements 
made, except where their names are cited in the text of the work. 

In the sections devoted to treatment the authors have depended largely 
on their own experience and that of the great body of physicians employ- 
ing the active principles, as presented in the pages of The Alkaloidal Clinic, 
and its successor, The American Journal oj Clinical Medicine. The 
superiority of these modern methods and remedies has been strongly 
impressed upon the writers by comparing them with their former treat- 
ment, as shown in a work written by Dr. Waugh before he began the use 
of the alkaloids. The improvement in prognosis is especially striking. 
In fact, that comparison enables one to realize the great advance in the 
art of prolonging life, that has resulted from the substitution of reliable, 
accurate and uniform agents for the old crude and uncertain weapons 
with which we feebly endeavored to cope with disease. The problem 
in organic disease is not now so much as to the extent and character of 
the lesions as to the remainder of vital force, and the intelligence of the 
patient. 

The substitution of the active principles for cruder vegetable prep- 
arations seems to the physician who has not made the change one too 
trivial to warrant the enthusiastic claims of those who have made it and 
mastered the applications of the new remedies. But in truth, it is little 
if anything short of a revolution in therapeutics. The certainty with 



ii PREFACE 

which we can apply in practice remedies that are uniform and precise 
in their effects, and whose powers have been accurately determined by the 
most scientific study and experiment; the rapidity with which the naked, 
soluble alkaloid gets to work; the ease with which the effects of single 
agents of this sort may be appreciated and the dosage accurately regu- 
lated; the application of these remedies to the pathologic conditions 
presenting rather than to the hypotheses expressed by the nosologic desig- 
nations of diseases; these and many other advantages result in placing 
the physician on a different plane as regards his clinical work. He insen- 
sibly gets in the habit of closely watching his cases, to appreciate the 
pathologic conditions and take cognizance of the effects of his remedies; 
he learns to intervene promptly and decisively, as he recognizes the oppor- 
tunity and knows his weapons; and inevitably his work acquires a decision 
and precision that produce similar characteristics in his mental habitude. 

As he ceases to speculate on the probabilities that may follow the 
administration of drugs, and acquires the habit of prompt and decisive 
intervenl ion, things become possible to him for which he would not previ- 
ously have made an attempt. His prognosis becomes more hopeful as 
self-confidence arises, as consciousness of power to control the situation 
becomes his prevalent state of mind. 

To the outsider this reads like a fairy tale; one who has not the experi- 
ence will not assimilate it. 

In conclusion we will state that active-principle medicine is not a 
school, nor a system; it has no creed to be embraced; it has no abjura- 
tion to exact. The remedies it advocates are non-secret, non-monopolistic; 
free as the air to every druggist and physician, to make, dispense and 
use, without paying tribute to any one. Their applications are based 
on physiologic experiments carried out with a precision absolutely impos- 
sible with the older remedies. They offer to the medical profession for 
the first time an opportunity to escape from empiricism and base its prac- 
tice on a strictly scientific foundation. Mystery and superstition are 
finally banished from therapeutics, and the medieval shadows dissipated 
by the broad daylight of knowledge. 

The work is by no means complete. Much, very much, remains, 
for generations of experimentors and clinical observers. But to him 
who has not been over the ground it will be a matter of astonishment 
that so much has been done. Now that for the first time this material 
has been collected and arranged, its applications reduced, though all too 
rudely, to system, we are amazed that the profession — including ourselves 
— has been so slow to appreciate it. 

Drs. Waugh and Abbott 



PART I 

Fever and Its Management 

Infectious Fevers 

The older works on practice devoted many pages to the consideration 
of fever and its treatment. This has entirely disappeared from the modern 
text-books, in which not a paragraph is devoted to fever per se, but every 
specific fever is treated by itself. The disadvantage of this to the young 
practician is obvious. He does not meet cases with the diagnosis accom- 
panying them, on a tag attached to the patient's body. He is, therefore, 
bewildered and knows not what to do, until with the assistance of com- 
petitors, or with the lapse of time too precious to be lost, he has succeeded 
in establishing a "diagnosis." Then the matter is easy enough — he 
has only to refer to his prescription books, to select a formula which has 
behind it the most illustrious name, or which contains the largest number 
of ingredients, and this he delivers over to his patient, with the comfortable 
conviction that his whole duty has been done! Nevertheless, he could 
easily recognize at his first visit the presence of fever, and without delaying 
a single hour he could and should institute an effective therapy, even if 
his observation had not revealed a single fact in addition to this one of 
a rise of temperature. 

Not that we are recommending or sanctioning the neglect of further 
investigation, and of making a name-diagnosis at the first moment when 
the evolution of the malady will permit it. This goes without saying. 
We are only insisting on the necessity of prompt intervention by the physi- 
cian at the earliest possible stage of the disease. 

There are some things that are always right for the physician, and one 
of these is to intervene, if possible, before a malady has become so firmly 
seated in the tissues affected that it will run its course in spite of his inter- 
vention. Our forefathers believed implicitly in the possibility of aborting 
pneumonias. Since their most formidable weapons fell from our degen- 
erate hands, the belief founded upon the use of their pilum, venesection, 
has faded away. We do not need the lancet today; we know what it 
accomplished, and how. Without its ill effects we cure by the use of not 
less powerful, but equally efficacious and less objectionable means. 



2 FEVER AND ITS MANAGEMENT 

Progress is never uniform, never general. It goes by leaps and bounds, 
advancing and receding, winning a foothold here and slipping back there. 
And when a permanent advance has been won at any point, it may be a 
long period before the contiguous territory ceases to be hostile land, in 
which we have merely established an outpost. 

In the science of medicine the pathologist has carried our banner well 
to the front; but the materia medica has not moved forward correspond- 
ingly. 

Pathology says: "What do you know as to the effects of drugs on the 
morbid conditions of the tissues?" And while awaiting the answer to 
this question we have settled down, in the treatment of fevers, into an 
expectancy as vicious as it is impotent for good. Why under Heaven 
these patient "expectors, " who sit still and let the disease run riot through 
the patient's body, should " expect" to be employed or paid, is one of the 
things no man has yet been able to explain satisfactorily — to the patient 
at least. If we must suffer the pangs of disease, why should we pay 
anyone for simply acting as a spectator? 

The doctrine we present here contemplates a different attitude of the 
physician, and one more in accordance with the views of his employer. 
He is to actively intervene in the case, every moment of its existence, 
from the time the first microorganism alights on the patient's tonsil until 
he is restored to his place in society. 

Accepting at their full value the conclusions of modern science as to 
the causation of disease by microorganisms, we shall base on them our 
system of treatment. There must be an avenue by which these patho- 
genic germs obtain access to the human body, and in the tonsils we find 
a point less perfectly protected than usual. The connection of tonsillar 
inflammations with rheumatism has been abundantly shown, and this has 
opened our eyes to the fact that a similar connection exists with other 
infectious maladies. In all epidemics of the eruptive fevers, typhoid, 
pneumonia, etc., many cases occur of tonsillar inflammation, some fol- 
lowed by attacks of the prevailing epidemic, and others not; and we 
find that many of those so affected also escape all subsequent epidemics 
of that malady. The only explanation as yet offered for this curious 
phenomenon is that the patients have been affected by the malady just 
enough to render them immune against it, though not enough to cause 
a typical attack. 

This being the case, it behooves us to pay special attention to the 
tonsils, and to meet every indication of inflammation of these organs with 
effective germicidal applications, such as saturated solutions of salicylic 
or boric acid, hydrogen peroxide, resorcin, the mineral acids, etc. The 



FEVER AND ITS MANAGEMENT 3 

principle is the most important thing — the selection of a remedy can be 
left to individual choice. But the chlorides have long been noted as 
effective remedies for the throat and the domestic gargle of salt water 
does not merit contempt. Possibly none is more efficient than chlorine 
water, readily prepared extemporaneously by placing in a 4-oz. vial a 
dram of powdered potassium chlorate, adding a dram of strong hydro- 
chloric acid, and as the fumes of chlorine fill the bottle adding water to 
make four ounces. A teaspoonful of this in an ounce of water, every one- 
half to two hours, is sure death to every microbe with which it comes 
in contact. 

But suppose the microbes have gotten past the door, and effected 
a lodgment in the body. Then we have the period of incubation. During 
this, what is going on? The invaders are gathering their forces, multi- 
plying, so that in a given time they may make their grand assault upon 
the vital forces. In the original settlements made by them there is a scene 
of the most intense activity. 

But what are we doing in the mean time ? Nothing. We are waiting. 
For what? God knows. 

In his struggle with the Catalans St. Cyr was accustomed to withhold 
his hand until the enemy had gathered into an army, that he might destroy 
it at once, instead of wasting his energies pursuing the elusive bands of 
guerillas. But we have no such resources for combating essential fevers. 
We are as powerless as ever when the grand attack is delivered, and still 
have to maintain our pose of observation. 

If the microbes are few in numbers during the incubative period, if 
they are not yet ready to deliver their blow, it seems the part of wisdom to 
choose this time to strike them, when they are weakest. But can we do it ? 
Are there any weapons that we can bring to bear upon them at this time ? 
There are two remedies that have been proposed for this purpose: 
One was introduced by an obscure country doctor in the West, who had 
observed its good effects in the treatment of snake-bites. This is echinacea 
angustifolia. This plant has been tried by many physicians, in the whole 
range of infectious maladies, and it is confidently asserted that it is a 
systemic or hematic disinfectant, combating the specific causes of these 
maladies, of every sort. In health it seems to have little if any effect 
upon the bodily functions. The nearest approach to an active principle 
of echinacea yet obtained is echinol. Of this gr. 1-6 may be given every 
half hour until its good effects are manifested by ameliorating the septi- 
cemic symptoms. As yet we are unable to give any indications as to 
full effect or the doses usually required; it is not toxic and should be 
pushed until the malady subsides. 



4 FEVER AND ITS MANAGEMENT 

The other remedy is sulphydric acid, in the form of calcium and arsenic 
sulphides. Either of these is to be given in small and rapidly repeated 
doses until the body is saturated with the drug, as shown by the odor of 
the acid on the breath and the skin. In some cases saturation is denoted 
by the occurrence of nausea. When this occurs the doses are to be given 
less frequently, just enough to keep the body in the state of saturation. 

The theory of its action is simple enough — the existence of any patho- 
genic microorganism in the body saturated with the sulphides is impossible. 
Keep up this saturation for a week, and no living bacteria can be found 
in the body. It matters not what may be the organism, all fall before this 
potent destroyer, say its advocates. 

Let us add that in spite of the bad name given it by the older physiol- 
ogists, there is absolutely no danger in this medicament, and no harm 
accruing to the user. Calcium sulphide has been administered to adults 
with gonorrhea in doses up to 40 or 50 grains a day, with only good 
results; and to infants with diphtheria in doses of gr. 2 every hour, with 
like safety. In these cases, however, there may well have been a neutrali- 
zation of the drug by the toxins of disease; but in seeking to temporarily 
inhibit the sexual function, calcium sulphide has been given to masturba- 
tors in similar doses, with success and no sign of toxic action. 

These methods are at your service, if you desire to try them. It is 
certain that many physicians in active practice are using them every day, 
and are enthusiastic in their praise. Moreover, it is stated as a fact that 
no mosquito, flea, bedbug, louse, chigger, redbug, or other insect parasite, 
will bite a person saturated with calcium sulphide; so that there seems 
much reason to believe that the parasites of microscopic size are no more 
able to withstand its influence. 

When Metschnikoff first announced the phagocytic action of the leuco- 
cytes, the startling idea was received much as Verne's quasi-scientific 
romances The hypothesis proved useful as a ready means of illustrating, 
figuratively, many phenomena, and has insensibly become fixed in our 
minds as a fact accepted. The power of nuclein to increase the number 
and activity of the leucocytes has been proved, and it is difficult to escape 
from the conclusion that acceptance of the phagocyte theory carries with 
it the logical indication for the use of nuclein in all maladies attributable 
to invading microorganisms. It has been found that of the standard 
nuclein solution doses up to a dram each twenty-four hours increase 
leucocytosis correspondingly. This remedy is therefore applicable in 
all infectious maladies. 

The next point we wish to discuss in the treatment of fevers, is that 
of intestinal sepsis. This is a matter deserving grave consideration. 



FEVER AND ITS MANAGEMENT 5 

The contents of the bowels are within the bounds of the body, and yet 
not 11 it, in so far as that they are outside the influence of its vital forces. 
They consist of highly fermentable material, swarming with bacteria, 
with the requisite heat and moisture, and the constant addition of fresh 
material to keep up fermentive processes. The activity, virulence and 
multiplication of microorganisms is vastly increased during any fever. 
The safety of the body lies in two factors: The constant movement for- 
ward and dejection of these matters, and the disinfecting action of the 
various digestant fluids, especially the gastric juice. 

That the first of these is uncertain requires no proof. Cases have 
been reported in which persons have ejected from the bowels substances 
swallowed seven months or more previously. What possibilities in the 
way of decomposition and autotoxemia exist here. The practice of 
beginning the treatment of every case by completely emptying the alimen- 
tary canal, is one strictly in accordance with modern science, and supported 
by common sense as well as by clinical experience. 

The influence of the liver in disinfecting the bowels has been largely 
overestimated. Recent investigations have shown that the bile is an 
excellent culture ground for various microorganisms, and that at least 
the colon bacillus may in the gall-bladder acquire pathogenic powers. 
The typhoid bacillus also retires there for recuperation, and descends 
thence into the bowel with increased virulence; and this is believed to 
explain certain relapsing cases of this fever. Besides, one of the invari- 
able results of fever of all sorts, is to decrease or suspend entirely the 
secretion of bile, and of all the digestive fluids; so that this means of dis- 
infection is cut off at the very time it is most needed. 

From this it is evident that in every fever a certain proportion of the 
symptoms is attributable to the decomposition of the contents of the 
bowels, and the absorption of the toxic substances thereby formed. The 
use of cathartics followed by intestinal antiseptics is therefore a routine 
procedure in every case of fever, of whatever nature. 

When these agents have been given in sufficient quantities to free the 
stools from all unpleasant odor, it will be invariably found that about 
40 per cent of the fever and other symptoms will have subsided. Espe- 
cially the muscular aching, delirium, headache, restlessness, general 
malaise, neurotic phenomena, insomnia and other general symptoms, will 
be moderated or entirely removed— and when 40 per cent of any febrile 
attack is dissipated, it must be a pretty poor sort of a doctor who can not 
handle the balance. Just here let us ask you not to tell us that the ali- 
mentary canal cannot be sterilized. We all know that; but nobody has 
claimed that such complete sterilization is essential, and the results of 



6 FEVER AND ITS MANAGEMENT 

actual applications of this system are amply convincing as to its utility, 
explain it as you please. 

Is it ever wrong to thoroughly empty the bowels and render tnem 
aseptic? Even the presence of local intestinal disease, such as tubercular 
or typhoid ulceration, does not constitute an exception; it only indicates 
a difference in the measures to be employed; for surely it can do an intes- 
tinal ulcer no possible good to be constantly bathed with fetid fecal matter, 
reeking with innumerable pathogenic organisms of many varieties. We 
will suppose that in such conditions the physician will give moderate 
doses of salines to liquefy the contents of the bowels, and that he will 
aid them by flushing the colon with lukewarm water containing non- 
toxic antiseptic agents, such as a saturated boric or salicylic acid solution, 
or zinc sulphocarbolate 5 to 10 grains to the pint. If there is no such 
intestinal condition to warn him, he will give his patient calomel, a grain 
in broken doses, followed by saline laxatives, until he is certain that the 
alimentary canal has been completely emptied. Then, if the offensive 
odor of the stools indicates it, he will give some such intestinal antiseptic 
as the sulphocarbolates, until all such unpleasant odor has disappeared. 
Adults require one or two scruples daily of zinc sulphocarbolate for this 
purpose; double these doses of the lime or soda salt. It is by no means 
to be taken for granted that one or more fluid stools, the last one light and 
odorless, indicate the complete removal of feces from the bowel. Some- 
times days or weeks may be required to remove accumulations that have 
been sidetracked or channeled for months. These may be discovered 
by palpating the abdomen or, as the writer has often proved, by the con- 
tinuance of symptoms indicating fecal toxem;a. 

We now come to the treatment of the fever, per se; and here again 
our practice is based on the soundest principles of modern pathology. 
For it is certain that the first step in every inflammation is derangement 
of the circulatory equilibrium, whereby an excess of blood appears in 
the inflamed part, with necessarily a corresponding anemia elsewhere. 
Now if we remove this excess of blood from the inflamed part and restore 
it to the parts that have too little, it is obvious that the subsequent steps 
of the attack, diapedesis of white cells, extravasation of blood, etc., cannot 
take place; and the malady is stopped — jugulated. 

We may accomplish this in two ways — by increasing the tonicity 
of the dilated vessels, or by relaxing those that are contracted and empty. 
The first object may be secured by giving the powerful vasomotor tensors, 
strychnine and digitalin; and these constitute the chief means employed 
by many leading physicians in the treatment of pneumonia. The second 
may be fulfilled by the administration of the vasomotor relaxants, vera- 



FEVER AND ITS MANAGEMENT 7 

trine and aconitine; and the first named, under the form of tincture of 
veratrum viride, is perhaps the most popular remedy in the United States 
today for pneumonia. 

Whichever is chosen, the same object is attained — the restoration of 
circulatory equilibrium. It is asserted that both these processes can go 
on together, the cells whose tonicity is below par taking up the tensors, 
while those in a spastic state absorb and utilize the relaxants. At first 
sight this seems unreasonable, but when we reflect that every living cell 
in the body selects from the blood what food elements it stands in need of, 
and rejects the rest, there is no special reason for refusing to credit them 
with a similar power as to the selection of medicines. And if it comes 
to that, is it so easy to draw the line between foods and medicines ? 

Besides, those who have put this theory to a practical test are unanimous 
in their reports, that the results are better than when either the tensors 
or relaxants, stimulants or sedatives, are employed alone. 

The basal prescription for fever is therefore aconitine and digitalin. 
The former stimulates cardiac inhibition, slowing and regulating the 
pulse, relaxing vascular tension and lowering temperature. Digitalin 
also strengthens inhibitory control, slows and strengthens the heart, 
restoring vascular tension where it is deficient. We speak of the water- 
soluble digitalin, whose effects are manifested within half an hour of its 
administration. To these Burggraeve added strychnine arsenate, con- 
stituting the Dosimetric Triad (amorphous aconitine and strychnine 
arsenate aa gr. 1-134, digitalin gr. 1-67). Strychnine is the most powerful 
vital incitor, energizing every organ and function of the body, especially 
combating the tendency to debility which increases with every day of 
febrile waste. This combination is especially indicated in adynamic forms 
and stages of fevers. It should be given according to the needs, every 
ten to sixty minutes, one to two hours, until the pulse gradually approxi- 
mates normality, at which it is to be sustained. 

The primary action of arsenic is the induction of fatty degeneration. 
Acting on the newly deposited debris of the febrile processes this is more 
quickly melted and put in condition to be removed by the lymphatics. 
To arsenic is less certainly attributed also the power of specifically improv- 
ing the nutrition of the heart-muscle. 

To the basal aconitine and digitalin Abbott added veratrine, consti- 
tuting the Defervescent Triad, or "Defervescent Compound" as commer- 
cially known. In small doses veratrine also increases inhibition, slows the 
pulse, increases vascular tension, not by contracting the lumen of the arteri- 
oles, but by directly increasing the power of the cardiac muscle fibers. 
Veratrine also opens every door of elimination, and is the most effective 



8 FEVER AND ITS MANAGEMENT 

medicinal agent known in removing from the body the toxins generated by 
the infectious agents, or by morbid metabolism, or those absorbed from the 
alimentary canal. It is therefore in its action a safeguard against toxemia 
and over-dosage. When the toxic action of veratrine commences this 
is first manifested by a sense of warmth outlining the stomach, when the 
remedy should be suspended, or given in smaller and less frequent doses. 
If pushed, as must be done in profound toxemias, like uremia, nausea 
and diarrhea will be induced and in still larger doses the heart will be 
depressed. We can not conceive of peril arising from the internal admin- 
istration of this alkaloid by any person of average intelligence who has 
been told of its effects as above described. 

The applications of this powerful defervescent compound are found 
in sthenic forms and phases of fevers, and all cases where marked evidences 
of toxemia persist after thoroughly emptying and disinfecting the bowel. 
In the doses advised veratrine should be looked upon as a cardiac tonic 
instead of a depressant. As compared with veratrum viride, the latter 
does not display the preliminary increase of vascular tension described; 
otherwise the action of the two is identical except that veratrine is uni- 
form, veratrum viride displaying the variability as to action and strength 
inevitable in all tinctures and extracts. 

In treating any fever those two combinations may be employed, one 
or the other, as asthenia indicates Burggraeve's Triad at one time, or 
toxemia indicates Abbott's at another. By changing from one to the other 
the general effect is sustained and the varying conditions are met. 

By these general measures the physician will have gone so far in the 
treatment of his patient that he may, in fact, find a name-diagnosis impos- 
sible, for what had presented every indication of developing into a pneu- 
monia, or typhoid fever, has so changed its aspect that in a very short 
time the patient is well; and the physician will find considerable difficulty 
in classifying his case, unless he has made those laboratory tests which 
afford some degree of certainty as to the microorganisms engaged. 

The development of the case will, of course, bring with it indications 
for special treatment, as the symptoms point to one malady or another, 
one locality or another affected; but if our young friend has improved 
the shining hour in the way we have suggested, he will have nothing to 
regret or retract, but will simply add the specific treatment indicated to 
that which he has already instituted. 

Especially do these remarks apply to. the treatment of the febrile 
maladies of infancy, the infections most common during this period of 
life; so also to the results of "catching cold." But the vast majority 
of non-specific febrile attacks in early childhood may be confidently attribu- 



FEVER AND ITS MANAGEMENT 9 

ted to the alimentary canal, and the treatment above described applies 
with peculiar force to such cases. 

This treatment applies to all fevers where the temperature is below 
105 F. Above the latter point we have hyperpyrexia, and here a special 
indication presents, for the delicate structures of the human brain cannot 
long withstand such heat and our intervention must be prompt and power- 
ful. Sometimes venesection is our best resource, bleeding to effect. Usu- 
ally we succeed best by applying cold to the scalp and skin, ice, or cold 
water, by baths, affusions or packs. Ice-water may also be thrown into 
the rectum. For the general practician encountering prejudices of the 
illiterate and working with unskilled assistants, an excellent plan is that 
of McCall Anderson: Have the patient lying on the back, covered with 
two blankets so folded that one may be turned down and the other up 
to quickly expose the patient's abdomen; to this apply a folded towel 
squeezed out of ice-water, and at once cover with dry flannels and replace 
the blankets. It requires but a few seconds to whip off the towel and 
apply a fresh one. This is to be done every minute for half an hour 
out of every two hours ; in the intervening time the abdomen is to be cov- 
ered with warm, dry flannels. Care is to be taken to avoid wetting the 
bedding; best by stuffing flannel, wool or absorbent cotton along the 
patient's sides. The effect on the temperature is decided, the relief such 
that the patient will overrule any objection on the part of the family, and 
the disturbance incident to shifting the patient to and from a bath is 
avoided. This method fully replaces the cold pack and is much easier 
as well as less terrifying to those unused to hydriatic procedures. This 
procedure may be employed in any case in which the temperature exceeds 
103 F., provided the duty of emptying and disinfecting the bowels is not 
neglected. We have no fault to find with the cold-bath treatment of fever 
except that those who advocate it seem inclined to rely too much on this pro- 
cedure, neglecting to remove the cause while seeking to smother the effect. 
Granting that the elimination of toxin is stimulated by cold baths, this is 
better accomplished by the use of veratrine and attention to the bowels. 

Elimination by the kidneys is so essential to the continuance of life 
that it must be one of the daily duties of the physician to see that it is 
sufficient. One of the best means of flushing the blood and kidneys is 
throwing into the colon a pint of decinormal saline solution, very gradually, 
at body temperature, to avoid exciting peristalsis. This also relieves 
thirst and muscular cramps. 

Each special form of fever may require special additions, or not, as 
the case may be; such as quinine for malaria, salicylic acid for rheuma- 
tism, pilocarpine for erysipelas, etc. ; and in every case the duty of render- 



io FEBRICULA 

ing the house and vicinity hygienically clean, of enforcing a proper admin- 
istration of the sick-room, of guarding against the spread of the infection, 
remains as imperative as of yore. In fact, the physician who believes 
in utilizing the resources at his disposal in the treatment of fever, will 
find his occupation strenuous enough to satisfy even Mr. Roosevelt. 
(The hygienic management of febrile maladies is treated at length in the 
section on typhoid fever.) 

FEBRICULA 

A very bright young lady physician; in an after-dinner speech which 
would have done credit to Depew, said that after graduating it was good 
to go to a hospital for a year, or to some other place, to learn something 
about diseases as they really are and not as they are depicted in text- 
books. It goes without saying that that young lady had had some years 
of actual practice or she could not so aptly have expressed the true con- 
dition of affairs. Not that we are finding fault with the text-books — 
they do the best they can, and describe typical cases — but somehow when 
we get out in the broad field of actual work none of our cases is typical. 
By diligent search we may find something approximating their descrip- 
tion in the corollaries, if there are enough corollaries — but you all know 
how it is. 

A few years ago we were taught that all the aberrant forms of con- 
tinued fever coming our way were surely typhoid, but we' imagine very 
few will take this ground now. 

Febrile attacks frequently appear and pass off, without pursuing the 
typical course of any known malady and without discernible evidence 
of local inflammation. They may last a few hours or several days. Many 
such cases are seen during the epidemic prevalence of typhoid fever, 
scarlatina, measles and other infections; and as some of the persons 
thus attacked display immunity against these maladies then and after- 
wards, it is presumed that they are atypic or abortive cases of the prev- 
alent disease. In others there is a non-diagnosed or diagnosable rheu- 
matism, pneumonia, tonsillar or other local inflammation, especially in 
children. 

Osier describes a third group where the attack comes from the inhala- 
tion of sewer gas or foul odors. The attack may be colicky, with vomit- 
ing and diarrhea, fever and chills, going on to collapse; or a low con- 
tinued fever with debility and anorexia. 

In the vast majority of these cases the condition is an autotoxemia, 
from the intestines. Not so often from the food — the gastric juice is 



FEBRICULA n 

wonderful in its power of disposing of abominations — but from the decom- 
position of fecal matter left beyond the normal period in the bowel, or 
deprived of the antiseptic action of the bile and other digestive fluids. 
This condition has been observed most frequently in children, because 
their impressible nervous systems have not as yet acquired toleration as they 
do in adult years. Clinically, this is shown by the promptness with which 
relief follows clearing out and disinfecting the bowels, and by the constant 
presence of constipation, bad breath and fetor of the stools, in these cases. 

The fever may run up to 104 F. on the first day, or may linger longer 
at 101 in the morning and 102. 5 in the evening for some days, or foi 
several weeks, without showing any distinctive signs of typhoid or of 
malaria. Headache, backache, nausea, anorexia, malaise, heavy breath, 
constipation, red and scanty urine, insomnia, and even a little nocturnal 
delirium, may be present. With children the most notable evidences of 
sickness may be impatience and crossness, loss of appetite, thirst, dis- 
turbed sleep and fetid stools. They vomit readily. 

The diagnosis is made by exclusion at first, the absence of definite 
indications of any known fever or inflammation narrowing the case down 
to the present category. As the physician gains experience he learns to 
recognize the malady at a glance, and his fears of typhoid are less fre- 
quently expressed. 

In the numberless mild cases that occur with children there is peace 
to the household in an efficient and palatable laxative, kept at hand and 
given whenever crossness or failure of appetite indicates the need. The 
alkaline syrup of rhubarb, with sodium sulphocarbolate gr. 10 to the 
ounce, in doses of one to four drams every two hours till the bowels move, 
answers well and often prevents more serious indisposition. In more 
severe forms give calomel, gr. 1-6 to 1-67 every half -hour for six doses, 
followed by a saline laxative, and enough zinc sulphocarbolate to render 
the stools inodorous. Aconitine for the fever is usually required — just 
enough to do the work, no more. After the bowels have been emptied 
and disinfected a few granules of juglandin, gr. 1-6 to 1-2 for a child, 
before each meal, with quassin gr. 1-67, if languid and relaxed, will soon 
restore the digestive secretions to their normal condition. If the fever 
has been high for a few days there may be quite a discharge of sabulous 
matter in the urine as the fever breaks; or a critical sweat. The diet 
should be as nearly nothing as possible, consisting of cool drinks, barley 
or rice water, weak soups or tea. Lemonade is useful and a good excipient 
for the simple remedies employed. 

These attacks may usually be avoided by attentive observation of 
the child. A heavy breath, coated tongue or simply a display of temper, 



12 FEBRICULA 

suffices to show that things are not right. If at this time the patient is 
given the requisite remedies to clear out the bowels, and a few granules 
of juglandin, the attack will be averted. 

Juglandin is a remedy whose value grows upon one the more he em- 
ploys it. It closely resembles rhubarb in its action, but has the advantage 
of a small dose and ease of administration, as well as uniformity of effect. 
It is laxative and tends to stimulate all of the intestinal secretions in a 
normal, healthy condition; hence it is a restorer of digestion. For a i 
child two years old one-sixth of a grain may be given every two hours, 
until it has acted on the bowels. For an adult from one to three grains 
before meals acts nicely. 

Quassin is highly regarded in France as a toner of the digestive system. 
This is a curious remedy in some respects, since it requires but an exceed- 
ingly minute dose, in fact the results seem to be due to the impression 
made by it upon the gustatory nerves. Take for an instance the use of 
a quassin cup: Into this we pour a little water; let it stand for a few min- 
utes, when on drinking it we find it decidedly bitter. Such a cup may 
be used daily for a year or more without its efficacy diminishing markedly. 
It is obvious that very little medicine is taken with each dose and yet the 
good effects are unquestionable. 

In France school-children are supplied with a drink which contains 
minute quantities of quassin, phosphoric acid and glycyrrhizin, the active 
principle of licorice. This is supplied by the authorities on the recom- 
mendation of the Faculty of Medicine. The acid tends to relieve thirst; 
the quassin imparts tone to the digestive mucous membranes and checks 
the disposition to immoderate drinking frequently manifested in very hot 
weather. The licorice covers the bitterness of the quassin and imparts 
a faintly sweetish taste to the beverage which renders it quite acceptable 
to the little ones. Such a drink would be useful in many cases of illness 
even more serious than a febricula. 

Salivas {La Dosimetric), speaks of a combination of veratrine, aconi- 
tine and brucine as in constant use for the medication of infants. Tous- 
saint pronounces this defervescent and decongestant triad very useful 
for these little patients. He prescribes it in the eruptive fevers, capillary 
bronchitis, pneumonia, bronchopneumonia, whooping-cough, croup, etc. 
In small doses these alkaloids moderate the great cerebral and respiratory 
centers, lower the temperature, and render less frequent and lively the 
cardiac and arterial contractions; rendering these agents in consequence 
sovereign defervescents, decongestants and calmants. 

Illoway reported good results from veratrum and aconite, which would 
have been better had he employed the alkaloids and added brucine. The 



SYNOQUE 13 

latter in small doses does not modify sensibility but increases the reflex 
excitability of the spinal cord; thence come reflex contractions of unstriated 
muscle fiber, and increased peristaltic movements of the stomach and 
intestines; digestion and defecation are facilitated, as well as miction 
and erection — in a word, brucine stimulates the entire organism and 
arouses the depressed vital force. 

SYNOQUE 

Ephemeral fever, a malaise rather than a malady, is characterized 
by slight gastric difficulty, a little aching and moisture of the head, followed 
by epistaxis or a patch of labial herpes and usually accompanied by a 
diminution of the urine, which is muddy and red. Two days' resting 
and dieting, a good washing of the digestive canal with saline laxative, 
and a diuretic drink, usually suffice to cure this indisposition. 

Synoque is a more serious malady, holding the middle place between 
the affection above described and typhoid fever. It shows rigors, intense 
heaviness, painful headache, a pronounced and obstinate saburral con- 
dition, offensive stools; and thirty years ago was called a "little mucous 
fever." In reality, whether simply inflammatory or bilious and mucous, 
as practicians still believe, it is a continued fever, which may last many 
weeks, and very often is only cured after prolonged convalescence. A 
chauffeur lay fifteen days with synoque, and on the twentieth day took 
to his bed with typical typhoid fever, of three complete weeks, after which 
it was two months before he could return to work. 

We look upon synoque as an abortive typhoid, a morbid infectious 
state in which the intoxication is insufficient to produce the typhoid state. 
The treatment, therefore, should be severe, the surveillance of patients 
very attentive and prolonged, to avoid relapses and disagreeable sur- 
prises (Toussaint). 

Synoque is very frequent in France at certain seasons; when the first 
cherries ripen, with melons and red apples, sweet wine and new cider. 
These lapses of diet, the overwork, the free drinking in hot weather, the 
forced work of sowing, harvesting and the vintage, render this disease 
in some places almost epidemic. 

The first indication is to combat the gastrointestinal condition with 
emetics and saline laxative. Next we oppose the fever with the defer- 
vescent alkaloids, given every half-hour when the temperature exceeds 
100. 4 F., at every hour when it is below 99. 5 F. Enjoin a liquid diet, 
give a small dose of saline laxative every morning, and satisfy the thirst 
with lemonade, soup, milk and bitter infusions. Toussaint advises calcium 



:_ SYNOQUE 

sulphide, S to 12 granules a day for the infectious element. On account 
: :ae intermittency and to prevent morning and evening rises of fever 
he gives with the sulphide two granules of quinine every hour during the 
afternoon. With children he prefers quinine hydr of err o cyanide, whjfr 
effect is very remarkable. If the patient does not digest milk well, it 
should be cut with soup deprived of fat. During convalescence solid 
food should be forbidden ::r a long period, or a relapse will occur, or 
death itself. The:\- £ a zread fever which may here occur, as well as a 
mee.: fever 

The French dosnnetrists have not yet learned the value o£ intestinal 
antiseptics like the sulphocarbolates, which so promptly put an end to 
such attacks as above described, when given to saturation after thoroughly 
emptving the alimentary canaL 

A lady, 34, married, without children, was seized with a fever in some 
respects resembling typhoid, but without the diagnostic symptoms. There 
was severe headache, principally in the forehead; coated tongue, fetid 
breath, tenderness in the epigastrium and fetor of the stools: but no 
rose spots nor ileocolic tenderness. The cise dragged along for several 
weeks, the fever rising to 104 F. in the afternoons, moderating somewhat 
in the mornings. There was no delirium at any time, but prostration 
without any of the hebetude characterizing typhoid fever. At the time 
this patient was under treatment autotoxemia was not well comprehended. 
However, the symptoms continued until the physician summoned courage 
enough to empty the alimentary canal by the administration of rhubarb 
and the use of colonic flushing, repeated daily for a week, while intestinal 
antiseptics were being adm in istered. When the bowels had been com- 
pletely emptied and the stools restored to their natural odor, the fever 
subsided and the accompanying symptoms disappeared. The tongue, 
whose coating had obstinately refused to yield to numerous efforts at 
treatment, cleaned up promptiy and health was quickly reestablished. 

A sailor was seized with a chill, followed by a rise of temperature to 
::_ : F., with delirium and intense frontal headache. The tongue was 
heavily coated, the breath offensive, the epigastrium tender and some- 
what pufry; the stools very offensive, the appetite entirely absent. The 
patient complained thai every bone in his body ached and he could get 
no sleep, being compelled to turn every few minutes as the bones on which 
he rested his weight soon became painful. Prostration was great. The 
eyes were somewhat injected, with photophobia; mild delirium occurred 
at night. The temperature reached 104. 5 c F. each evening, declining 
about one degree in the morning. The urine was scants* and verv high- 

CJ J J %J 

colored. This continued four days, when the patient's fever broke up 



TYPHOID FEVER 

with a profuse sweat and an enormous discharge of urine heavily loaded 
with urates. This followed the administration of calomel and saline, 
the patient having been kept on thin soup during his four 
Convalescence at once set in and the man returned to his duties at the end 
of seven days from the time he reported at the sick calL 

These cases are distinguishable from paratyphoid by the briefer course 
and the absence of the specific organ! 

TYPHOID FEVER 

Typhoid or entenc fever is an infectious malady caused by the typhoid 
bacillus. It is the common continued fever of the United States, and is also 
found in all parts of the world. Indeed, in dealing with any attack of 
tinued fever here, it is to be presumed to be typhoid until proved 

Two conditions are requisite for the production of t: r, a soil 

suitable for the growth and development of the bacillus, and its entrance 
into the alimentary canal, or possibly other mucosa, of a susceptible 
individual. 

Typhoid fever is most prevalent in the autumn, and after unusually 
hot, dry summers. Males and females are equally affected. It is a disease 
of young adults by preference, but has been seen in infants under one 
year and in men over six: S me :r jns appear to be immune. One 
attack generally protects, but second and even third attacks occur rar 
It has become the typical camp fever. 

The typhoid bacillus is a short, thick, flagellated motile rod, with 
round ends, one showing a bright spot. It is cultivable on various media 
and in this way may be distinguished from other organ:- pecially 

the colon bacillus. Cultures are killed by ten minutes* exposure to a heat 
of 6o° C, but may survive till the twenty-second week a cold of five degrees 
below zero C. The bacillus resists drvins: for months, but is destroved 
by exposure to the direct rays of the sun for four to ten hours. Cultures 
are sterilized by solutions of phenol, 1-2 per cent, or of mercuric chloride. 
1-25 per cent. 

It is not easy to demonstrate the bacilli in the stools, and even with 
improved methods Eisner could only do so in one-half hi- 
in fatal cases it was impossible. But they are usually to be found in the 
blood and the rose ^ :-: and have been found in the intestinal gk 
mesenteric gL leen, marrow, liver and bile. They have been 

detected in the urine in about one-fourth of the cases, and sometimes in 
the sweat, sputa, endocardial, pleural and meningeal fluids, and in 
purulent collections. 



16 TYPHOID FEVER 

In ordinary water the typhoid bacilli disappear in two weeks, being 
probably destroyed by other microorganisms. In ice they mostly die 
within two weeks, but have been found alive at the end of eighteen weeks. 
It is rarely possible to identify them in water, but Prudden detected them 
in filters. They develop rapidly in milk and may live three months in 
sour milk, or for some days in butter. In fecal matter and in the soil 
they exist for many months. They retain vitality in earth for 21 days, 
in sand 82 days, in street dust 30 days, on linen 60 to 70 days, on wood 
32 days. (Osier.) 

Direct contagion is rare; and only through the stools and linen. 
Foods are probably infected by dust containing the bacilli. Water infec- 
tion by the stools of patients suffering with typhoid is the most frequent 
source of transmission. Milk is so prone to take up this poisonous organ- 
ism that it is believed to have been infected by the water used to cleanse 
the cans. Many vegetables are now forced for market by watering them 
with diluted sewage, and here the danger of direct transmission is great. 
Oysters fattened in waters into which sewage is emptied become a source 
of infection. Flies walking on infected fecal matter carry the bacilli 
on their feet, to the food and perhaps directly to human beings. 

Dirt, offensive cesspools, decaying organic matters, can not in them- 
selves originate typhoid fever, but they probably offer congenial soils for 
the development of the germs, and then become sources of infection. The 
writer has made observations that led him to believe that the air from 
infected sewers conveyed to bedrooms by stationary washstands carried 
with it the typhoid infection; the, same has been claimed as to the air of 
infected privies. While these modes of infection have not been definitely 
proved it is going too far to say they are impossible, or even improbable. 

The most important thing to remember is. that infection comes only 
by means of the excretions, and if these are destroyed it becomes impos- 
sible. Were this to be fairly comprehended and acted upon, typhoid 
fever would soon become a thing of the past. It is within the power of 
every physician to absolutely prevent any case under his care becoming 
a source of further infection. 

Five groups are recognized by Osier: 

I. Ordinary typhoid with enteric lesions. These constitute most 
of the cases. The force of the disease is exerted on the glandular elements 
of the intestines, the mesenteric glands and the spleen being involved. 

II. Typhoid with slight intestinal lesions. There are symptoms 
indicating general septicemia with severe toxemia and high fever. 

III. Typhoid without any intestinal lesion. The bacilli are found 
in the blood, but no trace of disease is detected even after careful and 



TYPHOID FEVER 17 

skilled search. The cases are too few to justify the assertion that the 
bacilli can penetrate a normal intestine, or by any other route gain access 
to the body, but they render the latter a possible theory. 

IV. Mixed infections. There may be also present the tubercle, 
diphtheria or malarial organisms; or secondary infection with colon 
bacilli, streptococci, staphylococci or pneumococci, to which typhoid 
has opened the door. 

V. The studies of bacteriology have separated some cases which 
present the clinical symptoms of typhoid but are not accompanied by this 
bacillus. Others are present which differ in their cultures and agglutina- 
tion. These are now termed paratyphoid. 

From cultures of the typhoid bacillus Brieger isolated typhotoxin, 
and Martin a secretion that when injected into animals caused diarrhea, 
emaciation, degeneration of the myocardium and low temperature. 
Weaker toxins have been isolated from cultures of the colon and other 
allied bacilli. But as yet typhoid fever has not been produced experi- 
mentally by inoculations with the bacilli. 

Anatomic Characteristics: — The intestinal mucous membrane is in a 
catarrhal condition, to which is due the diarrhea. Desquamation of the 
epithelium attends it. 

The specific lesions are seen in the glands of Peyer. This morbid 
process begins in the upper part of the small intestine and progresses 
downward, becoming more severe until it reaches its maximum intensity 
near the ileocecal valve. By this time the glands earliest affected may 
be well on the way to recoveiy. It is not essential that all the glands 
in the intestine should participate in the morbid process, and some may 
escape entirely. It is of the utmost importance that this should be com- 
prehended, as upon it depends our method of feeding the patient. For 
if some of the glands were not at every stage capable of performing their 
functions we would have no chance to nourish our patient. The belief 
that all the glands are involved at once has even led to the dogma that 
nourishment is impossible and that the patient lives on his tissues through- 
out the whole course of the malady. 

The first stage of the glandular affection is hyperplasia, and this affects 
the structures of the small intestine most, but to some extent also those 
of the colon. The follicles are swollen and project from the surface of 
the membrane as grayish masses, from the size of a pinhead to a large 
pea. The process begins with hyperemia, then the lymph-cells multiply 
and infiltrate surrounding tissues, and the pressure empties the ves- 
sels. Some large polynuclear epithelioid cells are found, and others con- 
taining red cells. If the pressure is sufficient to cut off the blood-supply 



18 TYPHOID FEVER 

the process will end in necrosis; if not, resolution sets in. The hyper- 
plasia reaches its height in the beginning of the second week. If resolu- 
tion occurs the contents of the cells become fatty and granular, and are 
absorbed, the cell breaking down. The follicles subside rapidly, leaving 
the still swollen septa, giving the patches a reticulated appearance. Slight 
hemorrhages may occur, and small ulcers form. A similar condition is 
sometimes found in young children suffering with infectious fevers. 

Necrosis is attributed by Osier to the direct action of the bacilli. It 
may be limited to the mucous coat or extend through the submucous 
and muscular tissues and involve the serous coat. The sloughs cover 
the affected patches and solitary glands, varying in color from yellowish 
to black. 

The sloughs separate at the edges, leaving ulcers commensurate with 
the extent and depth of the necrosis. Ordinarily the mucous and sub- 
mucous layers are thrown off. The shape of the ulcers is irregular, as 
several may coalesce. The entire Peyer's patch is not usually lost. Heal- 
ing commences at the edges and the base, granulations covering in the 
gap, and the epithelium is regenerated. Local conditions govern the 
healing, which may be interrupted by extensions. The gland cells are 
restored, and the site of the ulcer denoted by a depressed pigmented area. 

Chomel said that perforation was due either to ulceration or to rupture 
of the thinned bowel by distention. The latter is the more common. 
It occurs in about five per cent of fatal cases. It is most frequent in the 
last part of the ileum, but occurs in the large bowel and sometimes in the ' 
appendix. It is possible as long as there are unhealed ulcers in the intes- 
tine, hence may occur during convalescence or after the patient has 
returned to his avocation. 

Fatal hemorrhage takes place in about 1-2 per cent of fatal cases. 
It is due to separation of the sloughs, rarely, if ever, to erosion of vessels. 

The mesenteric glands partake in the disease processes, becoming 
hyperemic, swollen and necrotic in many cases. Suppuration may occur. 
The glands corresponding to the most intense inflammation are most 
seriously affected. 

Early in the attack the spleen becomes enlarged, soft, infarctions are 
common, and rupture sometimes occurs. The liver is early affected, 
swollen, hyperemic, the cells becoming fatty and granular, with lymphoid 
and necrotic nodules. Abscesses are not unknown. Rarer complications 
are acute yellow atrophy, pylephlebitis, and affections of the gall-bladder. 

Acute nephritis or desquamation with granular degeneration of the 
tubular epithelium may occur. Lymphoid nodules are formed, which 
may break down into small abscesses. The typhoid bacilli are found in 



TYPHOID FEVER 19 

these and in the urine. Diphtheritic pyelitis, cystitis, and orchitis are 
occasional concomitants. Laryngitis, simple, diphtheritic and ulcerative, 
with necrosis of the cartilages, edema of the glottis, pharyngeal affections 
of similar nature, pneumonia early or late, hypostatic congestion, pul- 
monary gangrene, abscess and infarctions, pleurisy and empyema, arc 
more or less frequently met. 

. In the circulatory system we meet occasionally endocarditis, myocar- 
ditis, pericarditis, degeneration of the walls of the heart, endarteritis 
of the small vessels, and thrombi, cardiac or of local origin, more common 
in the veins than in the arteries. 

Meningitis of several types has been rarely observed. Parenchyma- 
tous degeneration of the nerves has been described; also optic neuritis. 
Granular degeneration of the nerve and muscle fibers is associated with 
prolonged high temperatures in this as in other fevers. Muscular abscesses 
may appear during convalescence. 

Symptoms: — The period of incubation lasts from eight to twenty-three 
days, according to the Clinical Society. During this period there are 
usually characteristic evidences of the coming attack. Osier says that 
in his 829 cases there occurred at the onset chills in 200, headache in 595, 
anorexia in 414, diarrhea in 322, epistaxis in 182, abdominal pain in 227, 
constipation in 152, pain in the right iliac fossa in only 6. 

The following symptoms were present during the incubation period 
in the writer's case. He has by inquiry found them in many other severe 
cases, and believes they would be frequently discovered if inquiry were 
made. 

The symptoms supervened gradually, so that there was no time when 
their beginning could be definitely fixed. There was first a sense of debil- 
ity, increased on attempts to "walk it off;" and worse after eating, when 
the abdomen swelled and cold sweat appeared on the face especially; 
flatulence and disturbed digestion, aggravated by laxatives; difficulty 
in getting to sleep, from aching of the bones on which the body rested, 
causing repeated turning, brief relief only ensuing; the slumber disturbed 
by disjointed, incoherent dreams, reminding one of the fragments of a 
dissected map; the dreams gradually developing into waking visions, 
the patient becoming conscious during the dreams, and dissipating them 
by opening the eyes; objects in the room began to take the shape of faces, 
leering, and changing into others by the corners of the eyes drawing out; 
couples of animals marching up to the eyes synchronously with the heart- 
beats, but vanishing when the eyes opened; dull headache; all these 
gradually increasing until the debility induced the patient to decide on 
remaining in bed. This is usually considered the beginning of the attack 



2o TYPHOID FEVER 

but as some will stay up longer than others, it is wiser to date the com- 
mencement from the first rise of temperature. When this is done the 
symptoms will be found to develop with remarkable uniformity. 

First Week: — In typic cases the fever rises steadily, two degrees each 
afternoon, and falls one degree each night; the pulse keeps pace with the 
fever, rising to ioo and 120, full but of low tension, becoming dicrotic, 
but often not till the second week. The tongue is coated white, tending 
to become red at the tip and edges, and to assume the small, pointed 
aspect characteristic of this fever. A strip down the center becomes 
dry, and later brownish. There is some flatulence, with diarrhea, and 
tenderness on deep pressure over the ileocecal valve. There is headache, 
aching of the bones on which the patient rests his weight, some hebetude, 
perhaps wandering of the mental faculties at night, a certain dullness or 
sluggishness of intellect. Sometimes there is wild fighting delirium. 
Slight epistaxis is common. There may be constipation, and some abdom- 
inal distress is usual if not universal. Mild bronchial irritation is com- 
mon, with cough, but little sputa. The stools are offensive. The spleen 
enlarges towards the end of the week. The premonitory symptoms 
described continue. 

Second Week: — The rose spots appear about the eighth day. They 
are like flea-bites, and the latter have been mistaken for the real typhoid 
spots. They are rarely numerous, and more frequent on the abdomen, 
though they may appear anywhere. They disappear on pressure and 
return. They fade in a few days and others appear. The previous 
symptoms are worse, the temperature remains high, the pulse becomes 
dicrotic if it has not done so before and grows weaker; headache is not 
mentioned by the patient, who grows more stupid and lies quiet. The 
stripe down the center of the tongue grows dryer and browner. Diarrhea, 
tympanites and abdominal tenderness are worse. Sordes collect on the 
teeth if neglected, and the breath is heavy with the odor of decomposition. 
Toward the end the dicrotism may cease. On the thirteenth day the 
temperature often takes a turn upward, above any point previously reached, 
and the succeeding depression is correspondingly lower. Danger from 
hemorrhage and perforation grows more probable now. Nervous and 
ataxic symptoms may become prominent. 

Third Week: — The remissions become deeper, the evening rise becom- 
ing likewise less; the pulse softer but still rapid. Debility and emaciation 
are evident. The mental symptoms clear up in favorable cases, and the 
appetite may become dangerous. In bad cases the pulse weakens, delir- 
ium and muscular tremor occur, or subsultus, muttering, carphologia, 
the abdominal symptoms increase in severity, and blood with detached 



TYPHOID FEVER 21 

sloughs appears in the stools. There is greater danger of hemorrhage 
and perforation now, and of pulmonary complications. In ordinary 
cases the end of this week sees the temperature normal and the patient 
out of bed. 

Severe cases may see even graver states in the fourth and subsequent 
weeks. Under the expectant plan the writer has known cases run along 
for thirteen weeks and finally recover. Emaciation and debility reach 
their highest point in protracted cases. The excretions are discharged 
involuntarily. Incautiously raising the patient's head may cost his life. 
Relapses, recrudescences and the train of complications and sequels may 
appear. But even in the least promising forms improvement may set 
in at any time, and the patient slowly recover. Convalescence in these 
forms is slow, and the degeneration of nervous and muscular tissues 
leaves an impress on the patient that may be permanent. Mental debility 
and even permanent aberration may testify to the profundity of the altera- 
tions made in the cerebral structures. Months and even years may be 
required to nurse the patient back to such mental and physical health as 
will allow of his resumption of the burdens of life. 

Analysis of Symptoms:— The most frequently observed form of the 
onset has been described. In one of the writer's cases, the patient was 
seized with wild fighting delirium, requiring several men to restrain him. 
This was a lusty young German, who recovered after an unusually sthenic 
attack. Other cases begin with severe headache or neuralgia, meningeal 
symptoms such as photophobia, twitching muscles, retracted neck and 
convulsions. In others the stupor is more pronounced, and there are 
evidences pointing to cerebral effusion. 

The pulmonary symptoms may be so prominent that pneumonia, 
pleurisy or acute tubercular infection may be suspected. Acute toxic 
gastritis, and appendicitis, have been diagnosed and turned out to be 
typhoid. Possibly in these the poison has been taken into the stomach 
in concentrated form. Others present the aspect of acute nephritis, with 
bloody albuminous urine, casts, oliguria, etc. 

In "walking typhoid" the initial symptoms are masked and the patient 
may continue at his work even into the third week. Such cases have 
even gone through the whole course unsuspected, and been recognized 
only after fatal perforation has occurred. In one of the writer's cases, 
a barber applied for advice for severe hemorrhages after three weeks' 
illness, with daily work at his trade. In another, a young girl came to 
the city from a town thirty miles off, and walked the streets for two days 
seeking admission to a hospital. A third, an Italian missionary, was 
brought for diagnosis to the hospital by a committee of colleagues. All 



22 TYPHOID FEVER 

three recovered, although as usual in these cases they had unusually 
severe forms of the malady. 

At first the face is flushed, the brows contracted from the headache, 
but the eyes are dull; and as the disease progresses unchecked the dull, 
stupid expression grows more marked. The bright eye of other fevers 
is rare. The blood is poisoned, not destroyed as in malaria. 

Fever: — The course of the temperature curve in a typic case is charac- 
teristic of this malady. During the first week the temperature rises about 
two degrees each evening and falls a degree each night, so that by the 
evening of the fifth day it has reached 104.5 F. The daily fluctuations 
are somewhat less during the second week. Lysis then begins, the morn- 
ing remissions becoming greater, the evening acme subsiding more slowly. 
When the attack continues into the third week there is apt to be a some- 
what higher temperature than in the second week, of the same character, 
lysis being postponed till the fourth or some subsequent week. 

While all cases do not pursue this unvarying course, there is a similitude 
to it in most, and the division by weeks is apparent even in prolonged 
attacks. Any marked variation from the typic course has its meaning; 
and in these we find our most highly prized prognostic signs. Sudden 
rises at the outset occur when the infection is intense and the attack begins 
with a chill or a convulsion. Inverted types have been recorded as curi- 
osities. A rise of a degree or more, especially in the third week, usually 
indicates an intercurrent pneumonia, which may not be denoted by the 
usual cough, the patient being too dull. A sudden fall indicates internal 
hemorrhage even before blood has appeared in the stools. A sudden 
drop, followed by a rise and abdominal pain radiating from the first point 
over the abdomen, are typical evidences of perforation. Hyperpyrexia 
is not common, but may precede death. Abortive cases are becoming 
quite common as the doctrine of intestinal antisepsis gains credence; 
the fever subsiding during the first or second week. 

During convalescence, imprudences in diet, exertion, or emotion, 
the visits of irritating friends and similar causes sometimes give rise to 
returns of fever, of some hours' or days' duration, termed recrudescences. 
These are not relapses, and have no anatomic lesions behind them. They 
indicate the extremely mobile state of the heat centers. But their occur- 
rence should lead to the most careful examination, lest they should really 
indicate pneumonia, acute tubercular infection, extension of intestinal 
ulcerations, or other grave complications. Even if the symptoms do not 
reveal it, the blood examination may show a leucocytosis. 

Sometimes the evening temperature will continue to rise for a long 
time without evident cause. The suspicion of tuberculosis arises, and 



TYPHOID FEVP;R 23 

this should be considered; but quite often it is a mere subjective symp- 
tom, and the disuse of medicine, care, and of the thermometer will put a 
stop to it. In the former case there will be continued emaciation and 
debility. 

Low temperatures are uncommon during the fever, unless the bath 
treatment is employed. During convalescence they may occur from 
defective metabolism and the interference with absorption through Peyer's 
glands, simulating obstruction of the thoracic duct in the effects. 

True relapses are not very rare, especially when the case has not been 
treated antiseptically. There may be reinfection from the gall-bladder. 
The course resembles the original but is shorter. 

Cases have been recognized in which there was no fever. 

Sometimes there is an initial chill. Chills followed by free sweating 
also occur; others herald the advent of pleurisy, pneumonia, otitis, perios- 
titis; occur after acetanilid or from emotional causes; but are usually 
to be taken as indicating septic invasions, most frequently the entrance 
of septic material through unhealed intestinal ulcers. 

The rose spots have been mentioned. They are elevated slightly. 
On fading after three days, they leave brownish spots. Sudamina and 
miliary vesicles follow free sweating. Purpura is unusual. The skin 
sometimes desquamates. The laches bleuatres formerly described are 
now ascribed to parasitic insects. Erythema is not uncommon during 
the first week. The tache cerebrate may be readily developed by drawing 
the nail across the skin; a red line with white borders. Herpes is rare. 
Gangrene of the skin sometimes occurs with children. The skin is gen- 
erally dry during the fever, but some cases have free sweating. 

Edema may be due to obstruction of vessels (local), to nephritis (gen- 
eral), or to poverty of the blood. The hair often falls after severe attacks, 
and sometimes the nails. Ridges are developed on the latter, or atrophic 
ridges mark the parts developed during the fever. The peculiar odor 
noted on some patients is another evidence of neglect of the toilet of the 
bowels. Whitish lines may appear on the abdomen and thighs, resem- 
bling "mother marks." Bed-sores may form when the patient lies very 
low, the skin wet by incontinent urine and the nurse neglectful. Cleanli- 
ness, relief of parts from too continuous pressure, and stimulating applica- 
tions, prevent or cure them. Boils are common sequels, especially after 
the bath treatment. (Osier.) 

Thayer, quoted by Osier, describes the following as the blood changes: 
Little change occurs during the first two weeks. In the third week the 
red cells and hemoglobin fall, to rise during convalescence. The hemo- 
globin falls proportionally below the red cells, and rises more slowly. 



24 TYPHOID FEVER 

The white cells are fewer than normal throughout, and the absence of 
leucocythemia is diagnostic. The large mononuclear and transitional 
forms are increased, the polynuclear neutrophiles much lessened in num- 
ber. Acute inflammatory complications show an increase in polynuclear 
forms. 

In convalescence the anemia may become extreme. 

The pulse is slow as compared with the fever; it is early dicrotic; 
the arterial pressure is lower as the debility increases, the capillaries relax- 
ing, the skin livid, and extremities cold. As the patient gains strength 
the pulse becomes normal, except that it is extremely mobile. Brady- 
cardia is more frequent than after any other fever. Osier has found the 
rate as low as 30. 

The heart-sounds may be normal; or the first sound weak, with a 
soft pulmonary systolic murmur. Gallop rhythm is common; embryo- 
cardia present in extreme weakness, the two sounds quite similar, the 
long pause shortened. Cardiac inflammations present their own evidences. 
Embolism and thrombosis of arteries are rare, the femoral being most 
frequently affected. Gangrene results in the area of supply. Venous 
thrombosis is more common, occurring in the veins of the legs. The 
phlegmasia subsides as the collateral circulation is established. Gan- 
grene following obstruction of the arteries is of the dry form. When 
both artery and vein are involved it is moist and rapid in its course. 

Anorexia comes first in time, and remains throughout. The thirst 
is marked at first, but is apt to be masked by the hebetude. The tongue, 
"small, dry, pointed, red at the tip and edges," is not now considered 
distinctive; yet it will frequently be seen. In the low stages it is apt 
to be cracked and ulcerated. With convalescence the coating is thrown 
off. Salivation is rare; the mouth usually dry. Parotitis may occur 
in the advanced stages, sometimes ending in suppuration. Pharyngitis 
is usual, sometimes membranous, which is apt to prove fatal. Esophageal 
ulcers may occasion dysphagia, and end in stricture. The stomach is 
generally the seat of mild irritation at first, soon lost in the more serious 
intestinal malady. Early nausea is not uncommon. Occurring later, 
it may indicate a serious complication. Diarrhea is not an essential 
element, and if present is not severe unless unwise medication or feeding 
is the cause. The stools are not more than five daily. Sometimes con- 
stipation is present. When the patient is restored to activity the persis- 
tence of diarrhea may indicate unhealed ulcers. 

The stools have long been likened to pea-soup; they are alkaline and 
offensive, yellow or brown. When the sloughs begin to separate blood 
is to be found in small or large quantities, usually only traces, with the 



TYPHOID FEVER 25 

separated sloughs. Hemorrhage is not usual before the end of the second 
week, and may occur at any time while the sloughs are separating. It 
may result from intense hyperemia. It is heralded by a sudden fall in 
temperature, with a sense of collapse, thready pulse, faintness, etc. Death 
may occur before the blood is discharged in the stools. It seems to be 
more frequent when the cold baths have been used enthusiastically. 

Flatulence is a discomfort and a danger, the gas pushing up the dia- 
phragm so as to interfere with respiration, and by distending the weak- 
ened intestinal walls, favoring perforation. Gurgling and pain on deep 
pressure in the right iliac fossa are generally present. The location of 
the pain here has led to operations for appendicitis. Pain may exist at 
any part of the abdomen where there are reasons for it. The peculiar 
pain of perforation and the consequent peritonitis has been described. 
When the ulcerations penetrate the muscular coat, localized peritonitis 
will cause pain and tenderness. 

Perforation may occur in any case, but is more frequent when ulcera- 
tion has been extensive. It rarely happens before the third week, and 
may occur at any time until the ulcers are healed, even months after the 
patient is up. The pain is most frequently on the right side. The bladder 
may be irritated. The muscles become rigid, with great distress on pres- 
sure. Sometimes the temperature falls, the pulse becomes feeble and 
rapid, cold sweat and other indications of shock are present. As peri- 
tonitis develops the leucocytes increase. The symptoms may be masked 
by profound toxemia. Respiration is hastened, hiccough appears early, 
and vomiting is frequent. The abdomen may be distended or flat, tym- 
panitic or dull from effusion. Other evidences, if any are needed, may 
be afforded by the cessation of peristalsis, the presence of air in the peri- 
toneum, the development of friction sounds within twelve hours, disappear- 
ance of liver dullness under gas accumulation, and pelvic fullness or ten- 
derness, as revealed by rectal examination. Rapid disappearance of liver 
dullness with an abdomen not much distended is a valuable sign (Osier). 

It may be difficult to make out enlargement of the spleen, which is 
generally present. 

Symptoms referable to the liver are uncommon. There may be 
jaundice, abscess, inflammation and suppuration of the ducts and gall- 
bladder, the latter rather frequently. Pain in the gall-bladder is common, 
with local tenderness and the pear-shaped tumor, with contraction of the 
rectus, not always jaundice. Gall-stones are a frequent sequel, due to 
typhoid bacilli penetrating the gall-passages. 

Epistaxis is common in the first stages, usually slight, but may be 
prolonged. Laryngitis, edema of the glottis, necrosis of the laryngeal 



26 TYPHOID FEVER 

cartilages, laryngeal paralysis, emphysema and stenosis, are infrequent 
occurrences. Bronchitis at first is almost a matter of course. Both 
catarrhal and croupous pneumonia occur. The latter may herald the 
onset of the disease, beginning with the traditional chill, the symptoms 
of typhoid developing later and possibly masked by the pulmonary malady. 
But it is in the later stages when the danger of pneumonia becomes greatest, 
when the patient is so stupid that the pulmonary affection may be over- 
looked unless the physician is on his guard. There may be no cough, 
no complaint, only an increase in the fever, with shallow or slightly hurried 
respiration, and an increase in the hebetude, the tongue dryer and browner, 
the pulse weaker and faster. Dullness may even be recognized and 
attributed to the hypostatic congestion also present, unless examinations 
are made after the position has been changed and sufficient time elapsed 
to allow the serum to drain from the uppermost lung. Sometimes the 
patient may by sharp commands be induced to raise a little "brick-dust" 
sputa "from the bottom of his lungs." 

Hypostatic congestion may be recognized by serous rales, dullness, 
disappearing or changing with change of posture, and shallow breathing. 
Fatal hemoptysis has occurred. Pleurisy is perhaps more common 
than is suspected. Pneumothorax has also been observed. 

It is difficult to distinguish between the cerebrospinal form and true 
meningitis, except by lumbar puncture and Kernig's sign. Delirium 
is less frequent under hydrotherapy, and absent under efficient antisepsis. 
It may be noisy at the start, but is generally quiet, muttering, apparent 
at night mostly, rarely maniacal. Sometimes it is sly, and the patient 
may escape and wander off if not watched. Alcoholic cases exhibit 
the features of alcoholic delirium. Usually the patient may be recalled 
to his senses by sharp questioning; but in bad cases he sinks into a pro- 
found stupor, in which he lies with eyes open, muttering or quiet, passing 
stools and urine in bed, constantly picking at the bed-clothes, the lips 
and tongue tremulous, the lower jaw fallen, opening the mouth, the ten- 
dons of fingers and wrists twitching. This state, which is neither waking 
nor sleeping, is known as coma vigil. The patient may lie on his back 
snoring, and yet be not asleep. Nothing is asked, as the patient feels nothing. 
He may need water badly, and a careless nurse may neglect to give it. 
The bladder may fill up, and incontinence of retention occur, the careless 
doctor neglecting to ask about it. Bed-sores are apt to form in this period, 
and if the nervous system is profoundly implicated the tissues may break 
down with inconceivable rapidity. The condition is one of great danger. 

Children may begin an attack with a convulsion, but this is rare in 
typhoid, unless complicated with acute cerebral inflammations or thrombi. 



TYPHOID FEVER 27 

Neuritis of the arm or leg may occur, with great pain and swelling. Mus- 
cles become sore, especially the calf, with cramps. The heel has been 
known to necrose when too steady pressure is made upon it. This may 
be avoided and comfort secured by placing a pillow under the knees. 
Handford speaks of tenderness of the toes, especially after cold baths. 
Multiple neuritis has appeared during convalescence. Poliomyelitis, 
hemiplegia, tetany and aphasia, are rare accompaniments. Insanity 
of various types has occurred as a sequel, usually temporary. 

Among occasional complications may be mentioned ocular disturbances 
and inflammations, pareses, hemorrhages, cataract and orbital throm- 
boses; otitis media may be the cause of a rise in fever. It is not usually 
serious unless neglected. 

Retention of urine may occur at any time, but is more usual in the 
stupid stage. The urine is scanty and concentrated, depending much on 
the quantity of fluids given, and on the sweating. 

Ehrlkh's Diazo-reaction:— Make a solution of hydrochloric acid, 50 cc. 
to 1000 cc; and saturate it with sulphanilic acid. Also make a one-half 
per cent solution of sodium nitrite. In a small test tube mix equal quan- 
tities of the urine and of a mixture of equal parts of these two solutions 
freshly combined, and shake well. One cc. of ammonia is then trickled 
carefully in so as to rest on top of the preceding mixture, when if the reac- 
tion presents itself there may be seen a deep brownish-red ring at the 
junction. Normal urine gives a light brown with no trace of red. If 
the diazo-reaction is present the color of the foam when the mixture is 
shaken, and the tint when largely diluted with water, are a delicate rose- 
red. 

This reaction is present in about two-thirds of the cases, and may be 
demonstrated during the first week and up to the twenty-second day. It 
occurs also in malarial fevers, tuberculosis, and sometimes in other acute 
affections with high fever. 

Typhoid bacilli are found in the urine of about one-third of the cases, 
rendering it turbid, and causing a peculiar shimmer- in the test tube speci- 
mens. They have been found in the urine for years after an attack. 

The urotoxic coefficient is high, and higher when baths are employed. 

Renal complications consist of albuminuria, of diagnostic value but 
not ominous; actute nephritis with higher fever, scanty bloody urine and 
back pain; nephritis in convalescence with anemia and edema; lympho- 
matous nephritis without symptoms; pyuria from typhoid and colon 
bacilli, or cocci; pyelitis, single or double, during convalescence. 

In the genital apparatus we occasionally meet orchitis, acute mastitis 
or hydrocele. Bone lesions are common and troublesome, such as perios- 



28 TYPHOID FEVER 

titis, necrosis and caries, chronic in course and recurrent. Arthritis is 
rare. Spontaneous dislocations of the hip have been recorded. Gibney 
describes the "typhoid spine," with pain in the lumbar and sacral regions, 
stiffness, pain on motion and tenderness but no increase of fever. The 
prognosis is good. 

Slight fevers ruffle the course of convalescence, possibly septic, prob- 
ably autotoxemic. Pyemia occurs, with numerous boils, fever and 
leucocytosis; or multiple chronic abscesses, or septic embolisms, or sup- 
purating mesenteric glands, splenic infarctions, parotid suppuration, 
pus formations, perinephric or perirectal, arthritic or osseous. 

Other diseases that sometimes complicate typhoid fever are erysipelas, 
measles, varicella, noma, diphtheria and acute rheumatism. Malaria 
is a disputed proposition. The physicians of malarial districts believe 
in the association, those who reside in northern cities are skeptical. 
Typhoid and tuberculosis coexist, are mutually mistaken, and the latter 
sometimes manifests itself during convalescence. 

Epilepsy, chorea and diabetes are suspended during the course of 
typhoid. 

Numerous forms of typhoid fever have been described, as it is modified 
by local and epidemic influences. Some attacks seem to expend their 
force on the brain, others on the lungs, the kidneys and other organs. 
Murchison describes the abortive, grave and latent varieties. In milder 
forms the symptoms are less severe, though similar; the temperature does 
not rise above 103 F.; the abdominal symptoms are not marked; and 
the patient is restored to health in ten to fourteen days. Abortive cases 
run their course in two weeks or less, the fever falling by crisis. Relapses 
may occur. 

In the grave form the fever is high, nervous symptoms prominent, 
depression marked and the course prolonged. Pulmonary and other 
complications occur. 

In the latent form, or walking typhoid, the symptoms are light, there 
is little digestive difficulty, and the patient may remain at work for nearly 
the entire term of the fever. Hemorrhage, perforation or sudden delirium, 
may first call attention to the affection. 

In the afebrile form patients show debility, depression, anorexia, 
headache, slow pulse, perhaps rose spots and enlarged spleen, but no 
fever. 

Children at any age are liable to typhoid fever. The fever rises more 
rapidly, the cough is more troublesome, and the nervous symptoms are 
more prominent. Delirium and insomnia are more common than intes- 
tinal disturbances. Serious hemorrhages and perforations are unusual. 



TYPHOID FEVER 29 

but aphasia, noma and affections of the bones are more frequent. The 
malady generally runs a mild and favorable course. Abortive forms are 
common. 

In the aged, typhoid fever is less common, but more fatal. Pulmonary 
complications and heart-failure are to be dreaded. 

Pregnant women are liable to typhoid, and about two-thirds abort. 
This is especially apt to occur in the second week. It is claimed that the 
fetus in utcro may be affected, but not necessarily. The Widal reaction 
has been obtained from the blood of the fetus and from the nursling. 

Relapses occur in from 3 to 18 per cent. They may be ordinary, 
coming after complete defervescence; or intercurrent, causing unusually 
protracted attacks; and spurious, commonly termed recrudescences. 
Immunity is slow in being established, and typhoid bacilli are found in 
the stools for years after an attack. Are they domesticated there, and 
reproduced ? 

Diagnosis: — Typhoid fever is quite common, exceedingly variable, 
does not hybridize with malaria, and while easily diagnosed in typical 
cases, is difficult or impossible in others. In typical cases we have the 
peculiarly uncertain onset, epistaxis, bronchial catarrh, digestive irritation, 
and the regular ascent of the temperature. The singular symptoms of 
the incubation period described may occur in other septic infections. 
The dicrotic pulse is suggestive. The rash does not appear until the 
diagnosis has been as a rule established by other evidence, and is con- 
firmatory. Tenderness and gurgling in the right iliac fossa are significant 
but not exclusive. Enlarged spleen occurs in other continued fevers. 
The absence of leucocytosis is strong evidence, and the presence of Ehr- 
lich's reaction confirmatory. 

With the majority of the above present, while not absolutely conclusive, 
we may ask: If not typhoid, what is it? And the weight of probability 
is so strong that we have a right to demand positive evidence to show 
the contrary. 

Positive proof is afforded by isolation of the typhoid bacillus from 
the blood, which can be done quite early; or from the stools, which is 
more difficult; or from the urine, which is easier, and may be done in the 
early stages; or from the rose spots, which is painful and possesses no 
advantages. 

Agglutination: — With an aseptic needle prick the aseptic lobe of the 
patient's ear, and obtain a drop of blood on a clean glass slide. Place 
a loop of bouillon culture from typhoid bacilli on a clean cover-glass and 
to this add a large loopful of a watery solution (1 to 50) of the dried blood 
specimen. Invert the cover-glass over the concavity of a hollow slide. 



30 TYPHOID FEVER 

and seal the edges with melted vaselin. Under a dry lens of high power, 
or an oil immersion twelfth, a rapid clumping of the bacilli in the hanging 
drop may be observed, and their movements cease almost immediately. 

The objection to the Widal method is that it may not be manifest till 
too late to be of practical value as directing the treatment. But it gives 
material aid in confirming the diagnosis, and convincing those who doubt 
the authenticity of every case which is aborted. 

Attacks localized in the cerebrum and spine are apt to be mistaken 
for meningitis. Examination of serum obtained by lumbar puncture 
clears up the obscurity. Cases beginning with symptoms of pneumonia, 
or early involvement of the pleura or kidneys, may likewise be differen- 
tiated by the bacteriologic investigation. 

Typhoid and malaria rarely coexist in the north. Each may take on 
the similitude of the other. Examination of the blood affords the only 
sure diagnosis. The more pronounced fluctuations of the fever, with 
the history of exposure to malaria, suggest the latter. 

Pyemia may resemble typhoid, but the chills and great variations in 
the temperature during a single day, with decided leucocytosis, indicate 
the former. Ulcerative endocarditis also presents an increase in the 
leucocytes. Tubercular maladies are distinguished by their bacilli, and 
the rapid emaciation. That repeatedly cases of typhoid fever have been 
operated upon as appendicitis, even in Johns Hopkins Hospital, shows 
how difficult the diagnosis may be. The presence of leucocytosis, and 
the absence of distinctive typhoid symptoms, usually serve to prevent 
this mistake. 

It must be exceedingly difficult to distinguish true second attacks of 
typhoid, since patients may have the bacilli in their stools for years after 
a first attack. If then they are seized with any of the above maladies, 
and typhoid bacilli are found in the blood or the urine, or Stools, how are 
we to tell if it be a second attack or not ? 

Prognosis: — The mortality varies in different epidemics. It is less 
in private than in hospital practice. Five per cent is very low; 20 per 
cent nearly as bad as is ever now reported. Osier's 829 cases gave a 
•death rate of 7.5 per cent. In the Spanish- American war the mortality 
was 7 per cent. 

Bad indications are very high fever, marked toxemia, delirium, abdomi- 
nal distention, hemorrhage, great or diffuse tenderness; or great depression 
with marked involvement of the nervous system, especially the symptoms 
pointing to that nervous collapse termed the ataxic state, one indication 
of which is dilatation of the pupils. Walking cases are dangerous; fat 
people bear the disease badly; women are more apt to die than men; 



TYPHOID FEVER 31 

pregnancy is malefic; organic disease of the heart or other vital organs 
adds to the gravity. But the worst prognostic is the habitual use of malt 
liquors by the patient. In such cases the heart is apt to fail just when 
its endurance is most needed. In the period of greatest depression sudden 
death has resulted from incautious elevation of the head. In convales- 
cence perforation has ensued after indulgence in solid food, though this 
danger has been exaggerated. Perhaps one of the chief elements in the 
prognosis is the physician's recognition of the dangers of toxemia, and 
its main source in the alimentary canal. The hygienic conditions of the 
house and its surroundings influence in the most decided manner the 
severity of the case and its course to recovery or to death. 

Prophylaxis: — If the typhoid bacilli given off in the urine and feces 
of each patient were destroyed, or if they found no entrance into the drink- 
ing water or food, or any suitable soil for their development and propaga- 
tion, there would soon be no more typhoid fever, the germs having become 
extinct through the working of natural causes. 

As a disinfectant and germicide lime has been proved effective. It is 
cheap, safe, easy to procure, and anybody can use it. Neither lime nor 
any other germicide acts instantaneously. Time must be allowed for 
the fecal masses to be permeated, and the bacilli to be destroyed. Use 
a large surplus, to make sure. Let the discharges be passed into vessels 
containing several quarts of freshly mixed whitewash, and after covering 
the vessel let it stand for an hour before emptying it. 

See personally that the house and vicinity are put in perfect sanitary 
condition. We have no words in our vocabulary strong enough to express 
our contempt for the so-called physician who attempts to treat a case of 
infectious disease like typhoid fever, and never gives a thought to the 
domestic hygiene. See that cellar, yard, alleys, adjoining lots, gutters 
and street, as well as cesspools, are cleared of all organic matters that may 
afford a nesting place for morbific germs. Empty and disinfect offensive 
cesspools. Open up wet cellars to the sun and air. Especially, if there 
is a well on the place in use, see if there is surface drainage into it. A 
good day's work may be done in attending to these matters. In the 
city the house drainage must be seen to. Especially important is it to 
exclude the stationary washstand from the sickroom. Thorough cleanli- 
ness, constant and abundant ventilation, are more important even than 
drugs or diet. 

Place the patient in an isolated room, capable of free ventilation, and 
put a nurse in charge w T ho will exclude unneeded persons rigidly. Have 
a tub of water containing some efficient disinfectant, in which all linen 
may be soaked before taking it from the room. Another vessel should 



32 TYPHOID FEVER 

be employed for dishes. Phenol, one part to 20 of water, or chloride of 
lime, will answer well. Linen should be soaked for two hours; dishes 
need simple rinsing. Food fragments should be treated as the discharges, 
to insure their not being eaten by children. A qualified nurse will see 
that her hands are disinfected after handling the patient, and especially 
after touching the discharges. 

During epidemics every means should be taken to prevent the use of 
possibly infected drinking water, milk, oysters, fruit exposed to street 
dust, etc. Camps should be laid out so as to avoid infection of the water 
supply and the campers instructed in the dangers and means of avoiding 
them. Feces and urine should be well covered with earth as soon as 
dejected so as to prevent the contact of flies. Boiling the drinking water 
is surer and pleasanter than the addition of any chemical disinfectant. 
But the use of a tinge of permanganate of potassium is to be commended. 

The evidence is favorable as to the efficacy of Wright's prophylactic 
serum. The injections cause local irritation, faintness, fever and uneasi- 
ness. 

A. F. Wright reported favorably on his experience with many thou- 
sands of antityphoid inoculations in the British army, finding the incidence 
lessened one-half in the inoculated, and the mortality of those attacked 
more than 50 per cent less than of the uninoculated. Protection endures 
between two and three years. Chantemesse reported the mortality in 
756 cases treated with his typhoid antitoxin as only 4 per cent, compared 
with an average mortality in other Paris hospitals of 18 per cent, and a 
minimum of 12.8 per cent. Einhorn also favors the serum. 

Treatment: — The objections to the intestinal antiseptic method may 
be thus reduced to logical terms: 

All the phenomena encountered during a case of typhoid fever are 
due to the typhoid bacilli. 

These bacilli, even in the incubative period, may be found in the blood 
and beyond the reach of intestinal antiseptics. 

Therefore these agents are useless. 

Also: — Unless every microorganism in the alimentary canal is destroyed 
by antiseptics they are useless. 

The antiseptics will not destroy every microorganism in the alimentary 
canal. 

These agents are therefore useless. 

In both formulas the major premise has not only never been proved 
but is absurd on its face. Yet on these the condemnation of the antiseptic 
method has been based. The technic of this method and the reasons for its 
advocacy are detailed in the introductory chapter on the treatment of fevers, 



TYPHOID FEVER 33 

Not all cases pursue an eminently satisfactory course under the anti- 
septic method; but the severe forms become scarce, the abortive cases fre- 
quent, and the disease puts on a milder aspect. If the neighboring physi- 
cians continue meeting bad forms, the object-lesson becomes impressive. 

The sooner the antiseptic method is put in practice, the more decidedly 
will its good effects be manifested. If the case is not treated until ulceration 
has occurred, or until the patient's condition is desperate, and the believer 
in antiseptics is then called on to demonstrate his miracles, failure is proba- 
able. The sulphocarbolates will usually prevent the dangerous con- 
ditions of the third week, but there are better remedies to promote the 
healing of ulcers, prevent perforation and stop hemorrhage; also to com- 
bat pneumonia. 

But when the sulphocarbolates have been given early in the attack, 
in the manner described, there is little to be apprehended in the way of 
complications and sequels. 

When ulceration has taken place and grave symptoms are present in 
the third week, the oil of turpentine has long enjoyed a well-deserved 
reputation. Give five drops every two to four hours, in capsule or egg 
emulsion. Tympanites quickly subsides, the tongue becomes moist 
and loses its brown central stripe, and the stools become healthier. This 
remedy combines the effects of an antiseptic with a stimulant which pro- 
motes healing. 

Hemorrhage is best met by ice to the abdomen, and silver nitrate, a 
grain a day, in divided doses. Sudden and dangerous bleeding is con- 
trolled more quickly by atropine, gr. 1-67, hypodermically, the dose being 
repeated so as t© keep the blood in the skin and out of harm's way. Tur- 
pentine should be begun whenever there is a trace of blood in the stools, 
or the sloughs appear in them. 

Threatened perforation is averted by turpentine. If it occurs the 
abdomen should be promptly opened and the diseased gut resected. But 
an aseptic bowel will not break, and will not be dangerously distended. 

Diarrhea never requires treatment beyond zinc sulphocarbolate and 
bismuth. 

Constipation is best relieved by the occasional use of calomel and 
salines as suggested, and colonic flushing. 

The nervous phenomena are inconsequent under the zinc treatment. 
Restlessness, etc., is almost always an indication of imperfect intestinal 
antisepsis, or of bad nursing, unwholesome visitors, improper food, etc. 
But a few small doses of zinc or caffeine valerianate will often give great 
relief, seemingly out of proportion to the powers of the remedy (gr. 1-6 
every hour). 



34 TYPHOID FEVER 

Bed-sores are prevented by placing the patient on a woven wire frame 
without a mattress but a couple of blankets over the wires. This gives 
a cool and well-ventilated bed, into which the patient will sink as in a 
hammock and the weight be evenly distributed. Absolute cleanliness 
is required, and urine especially must be washed away and the skin dried 
at once. If the skin reddens it should be rubbed with alcohol, with a 
little camphor added. 

Dilatation of the pupils and other evidences of ataxia call for zinc 
or caffeine valerianate, a grain of either every two to four hours; or for 
some other of the antispasmodic group. Musk was the ancient remedy. 

The diet usually preferred is milk; but for many years this has been 
avoided by the writer. The raw white of egg, dissolved in ice-water, is 
the one food which does not require digestion, being directly absorbed 
into the chick without passing through a digestive system. In fact, if 
the intestinal glands are universally affected it is difficult to see how any 
other food can be utilized, the patient being precisely in the condition of 
one whose thoracic duct is obstructed. The white of an egg may be 
given every two to four hours. The writer usually gives it every four 
hours, and half way between these doses gives four ounces of coffee made 
with milk, or rich with cream, or of freshly pressed grape or other fruit 
juice. Sometimes use is made of the predigested foods. Plenty of water 
must be prescribed in regular doses, as the patient is not apt to ask for 
it, and the inexperienced nurse will forget it. 

If more nourishment is needed, bovinine may be given as freely as the 
patient can manage it — a tea- to a tablespoonful every two to four hours. 

The writer has never seen any benefit from the use of any form of 
alcohol; and has not given it in typhoid fever for many years. 

The mouth should be frequently washed out with cool water, to which 
is added some pleasant, non-toxic antiseptic. The aromatics offer suitable 
agents. 

Serum therapy has not as yet scored a success in typhoid. Possibly 
in time it may develop so as to give results approaching those of effective 
antiseptics. 

Many other intestinal antiseptics have been recommended. Illings- 
worth advised mercury biniodide, Novy acetozone, Kesteven eucalyptus, 
etc. The results they report show the possibility of valuable effects from 
these agents. The writer has not obtained as good effects from any others 
as he has from the sulphocarbolates. 

Convalescence: — Dangers multiply as the patient begins to improve, 
to feel an appetite, and to take charge of himself. The judgment is often 
wabbly, and strange fancies disturb him. The writer well remembers 



TYPHOID FEVER 35 

that during his convalescence his fixed purpose was to prosecute for mal- 
practice the faithful physicians whose skill and devotion had brought him 
through. 

New foods should be added slowly and singly, and their effects watched. 
Over-eating, the too-speedy allowance of solid food, over-exercise, dis- 
turbing and unwise visitors, are to be avoided. The best tonics are the 
digestants, with mild chalybeates, the natural waters especially. Zinc 
oxide is a good remedy to promote healing and dissipate gastric catarrh. 
Berber ine restores tone to the relaxed intestinal walls; a grain a day in 
divided doses is the average dose. Rest, quiet, passive exercise and 
massage, with change of scene, salt air and bathing, are useful, especially 
when the enfeebled mental faculties render a speedy return to business 
cares inadvisable. Complete restoration from very severe attacks may 
never take place. 

Control of the case should be retained by the physician as long as there 
is an unhealed ulcer. The remedies for this condition should be changed 
each week. Turpentine, silver oxide or nitrate, europhen and zinc oxide, 
may be usefully alternated, each being given up to the limit of tolerance. 
The intestinal antiseptics are usually required till the patient is able to 
take a full allowance of exercise. 

One of the singular features of typhoid fever is the absence of leuco- 
cytosis. If this depends on the general implication of Peyer's glands, 
it indicates the possibility of these structures being participants in the 
elaboration of the leucocytes. 

The writer has to go back to the years before he learned to use anti- 
septics, to recall the various accidents and incidents figuring in his severe 
typhoids; and so he has neglected to speak of some of them. Hypostatic 
congestion calls for frequent changes of position, that no part of the lung 
may be unduly weakened by too-long soaking in the exuded serum. Add 
the use of sanguinarine, gr. 1-20, every two to four hours, to increase the 
vitality of the pulmonary tissues. The same remedy is useful in typhoid 
pneumonia, with stimulant liniments and good feeding. 

The heart must be especially watched in aged subjects, but tonics 
must be given judiciously, or reserved till the need is manifest. In per- 
sons over sixty, the use of moderate doses of digitalin or strychnine may 
forestall heart-failure, while its excessive use might exhaust the suscepti- 
bility and hasten the danger. But persons habitually accustomed to alco- 
hol should be stimulated from the first, and strychnine may be required 
in very large doses. 

The results of the treatment herein advocated are most satisfactory. 
Self-advocacy would seem to be prominent were the writer to state his 



36 TYPHOID FEVER 

experiences, and he will content himself with the recommendation to his 
professional brethren, that they try the methods and judge for themselves. 
He gladly accepts the American physician as a jury. 

Burggraeve began his treatment by washing out the alimentary canal 
with effervescent magnesium sulphate. It seems singular that those who 
fully appreciate the importance of good hygienic surroundings, and the 
dangers of allowing collections of putrescible organic matter to remain 
in the patient's vicinity, should overlook the possibilities resulting from 
quantities of the deadliest infective material actually within the patient's 
body and being absorbed into his blood. 

He followed with strychnine and quinine arsenates, for the adynamia 
and prostration, one or two granules each, every half-hour, as long as the 
fever oscillated between 102 and 104 F. When the fever tended to become 
continuous he had recourse to aconitine, vera trine and digitalin; watch- 
ing for complications, with emollients, revellents and dry cups where 
needed. Agitation, insomnia, trembling, etc., should be quieted with 
morphine, hyoscyamine, strychnine, cicutine, etc. When the pulse and 
temperature had been brought to nearly normal, he gave quinine hydro- 
ferrocyanate as a febrifuge and reconstructant, three or four granules 
every half to one hour. 

To keep the digestion in good condition he gave also quassin and soda 
arsenate, one or two granules every hour. 

Under this treatment the venerable Father of Dosimetry claimed these 
results: "Vainly have our opponents attempted to show that our diag- 
nosis of the patients cured was incorrect; we have jugulated too many cases 
for that; our diagnosis could not always be wrong; and if we have jugu- 
lated some of them, why may we not have also jugulated the others?" 

* D'Artigues writes in La Dosimetrie of some cases of typhoid fever, 
selecting, as he says, "the gravest among the gravest," for his illustrations, 
those in which the dosimetric treatment was only instituted when the 
patient was in extremis. "The first was the daughter of a physician, 
'allopath,' aged sixteen years. In the midst of an epidemic she was 
seized with typhoid fever, with the gravest ataxio-adynamic phenomena. 
Delirium was constant, fever of extreme intensity, diarrhea alternated 
with constipation. The usual remedies had been employed, including 
quinine; and the two consultants had retired from the case as hopeless. 
The father, alone, desperate, recalled the advice of D'Artigues, and decided 
despite his skepticism to employ the alkaloids dosimetrically. Following 
the directions of Toussaint's Medicine simpliste (the French equivalent 
of Abbott's Alkaloidal Digest), considerable improvement was mani- 
fested, and the girl opened her eyes, the first time in eight days. The 



TYPHOID FEVER 37 

intensity of the fever had much diminished, and when the two consultants 
returned the next day they were amazed at the change. The child recov- 
ered completely. Such facts, which can not be attributed to a lucky 
chance, must shake the most deeply rooted prejudices. But, as further 
proof, we have even interrupted the dosimetric treatment at the moment 
when a striking improvement had been produced, and after a very short 
interruption have seen reappear the whole series of primitive symptoms, 
including the elevation of temperature. 

"At other times we have seen an elevation more or less marked of the 
fever, and a light exacerbation of other symptoms,- follow some slight 
diminution of the granules, and vice versa. Just so the surgeon, con- 
trolling the flow of blood through a severed artery, may by raising or drop- 
ping his finger cause the jet of blood to appear or to cease. 

"The muscular debility that characterizes this malady extends to the 
heart muscle and the muscular arterial coats as well; and weakening the 
circulation causes liability to congestions. The lungs receiving all the 
blood from the right heart are especially liable to this congestion; but 
in all the other organs this enfeebling has this effect. The red globules 
coming less frequently to the lung, are less often aerated; hence the 
characteristic asphyxia, evident in grave cases and in advanced stages, 
but beginning as soon as the force of the circulation is diminished. This 
latent asphyxia is apt to become manifest when the prodromic stage 
dawns and general lassitude is felt. This should direct attention to 
the weakness of the heart and arterial walls, invisible as yet, but which 
can not fail to cause cerebral and other troubles which are perfectly 
evident. The blood, no longer restrained by the normal tone of its 
vessels, obeys the law of gravitation and settles toward the more 
dependent parts. Hence the vertigo, darkening of vision (eblouis- 
sement) and pallor when erect; abdominal congestion and tendency 
to hypostasis. The vascular pressure diminishes as muscular debility 
increases. Thence the acceleration and dicrotism of the pulse, the 
alteration of the red cells in all the organs, and their lessened oxygena- 
tion; then a sort of autointoxication by these altered globules, increas- 
ing the muscular weakness and causing disorders the more severe 
as the number of the abnormal cells is greater — that is, in plethoric sub- 
jects — a point confirmed by clinical observation. As the pressure falls 
the pulse accelerates and yet the velocity of the blood current diminishes, 
from feebleness of the cardiac impulse. We insist particularly on this 
last proposition, as it is vital to the question we are discussing, and the 
contrary opinion has been almost universally accepted as true without 
examination. This forms the keystone of the study of the lesions and 



38 TYPHOID FEVER 

symptoms of this malady. If the theory has a fault it is that it is too easy 
and simple. It seems difficult to admit that in all the entanglement of 
morbid phenomena of this fever there is no mechanism more complicated. 
(Note: — The French, the most careless of civilized nations as to hygiene, 
have not as yet begun to recognize the vast importance of intestinal sepsis 
and antisepsis in this malady.) If then there exists an agent capable of 
dissipating congestion in any organ, it should also dissipate it in all other 
organs. Whatever this agent may be, it can cause to disappear at least 
momentarily the varied troubles that depend on these congestions. An 
agent endowed with an excitomotor power more marked than others can 
modify even profoundly the course of the malady, if administered in doses 
appropriate to each case and with perseverance until the muscular system 
has had time to resume its own proper energies. 

"But whence comes this muscular enf eeblement ? It is today uni- 
versally attributed to the microbe in the blood. As to the mechanism by 
which it alters so profoundly the muscular system, that is far from being 
elucidated. It is doubtless possible that the typhoid or typhogenous 
poison alters the muscular fibers only through the intermediation of the 
nerves that animate them. If we admit by preference a direct action of 
the poison upon the muscular fibers, it is only to render the hypothesis 
easier to seize. But we must admit our inability to decide between these 
views. Nor do we know whether quinine, cold water, the alkaloids or 
phenol reestablish contraction of the muscle fibers by direct action or by 
affecting their motor nerves. But whether the action is direct or indirect, 
it is no less certain that it occurs; that the contractility of all the muscles 
of the body is notably enfeebled in typhoid fever, and that this inevitably 
produces the troubles of circulation and nutrition we have mentioned, 
and which everyone knows; troubles which constitute in themselves the 
entire syndrome of typhoid. 

" Are there among the remedies employed, ' allopathically, ' any endowed 
with such properties as will enable us to presume, in the absence of demon- 
stration, that they can fulfill the above indications ? May one be substi- 
tuted for another, or do they constitute a hierarchy in which one is prefer- 
able? Can these medicaments act on the muscular contractility, either 
by augmenting it when normal, or by restoring it when impaired? 

" Quinine causes fibrillary tremors when administered in massive 
doses; under the influence of cold water the unstriated cutaneous fibers 
contract, the skin showing gooseflesh; and phenol in toxic doses causes 
very violent tonic convulsions. These are then excitomotors and fulfill 
the indication that dominates in the whole course of typhoid fever, as 
the alkaloids fulfill it. The question is as to the relative value of each, 



TYPHOID FEVER 39 

the real utility and the facility of application. Take an equal number 
of extremely dangerous cases, treated by the methods we may term allo- 
pathic, and by the dosimetric methods. We have made this comparison 
many times, and declare, without the least hesitation, that the neuros- 
thenic alkaloids enjoy a very great superiority over the other medica- 
ments. Quinine is useful in grave cases, where it lowers the fever, but 
it does not appreciably abridge the course even in medium cases, and is 
absolutely impotent in very grave cases, in any dose. But within twenty- 
four hours, after administering the alkaloids, varied in accordance with 
the symptoms, opiate against spasm, hyoscyamine, aconitine, cicutine, 
when indicated — and quinine when exacerbations and remissions occur — 
the whole formidable cortege of symptoms, if they do not disappear, at 
least exhibit a change the most favorable and altogether unexpected when 
not so treated. What astonishes one is that the alkaloids dosimetrically 
administered can lower to a notable degree the gravity of the attack, 
abridge the duration of grave cases, abort benign ones, and even prevent 
the development of the disease in the prodromal period. 

'One can only deny a priori that which contradicts a fact already 
proved; but what is contradicted in admitting that typhoid can be modi- 
fied in its course by means differing from those previously employed with- 
out success? What is needed to rescue the typhic from the grasp of his 
malady? Always and always, contractile force. What then so strange 
that a little force in the outset has a better effect on the organism than 
a great development of that force at a more-advanced period? What 
is needed to extinguish a fire ? Water. What at the beginning ? A little 
water. What when the fire has gained headway? Much water; and 
later, all the water of the ocean will not suffice but to save the remains of 
the burned building. 

"We do not advise the alkaloids exclusively in treating typhoid. We 
prefer them as permitting more scientific treatment than other remedies; 
but we combat the saburral state by copious and repeated intestinal lav- 
ages; we jugulate the fever by the dosimetric triad (aconitine, digitalin 
and strychnine arsenate); assure intestinal antisepsis and prevent fecal 
absorption; and we sustain the patient's forces at all periods of the disease. 
Quinine acts only in solution and is powerless in very grave cases, it is 
excessively bitter and difficult to give to children and many others, and 
it is too costly for the poor. The alkaloids on the contrary are prompt 
even in very grave cases, they are most easy of administration and accept- 
able to the most recalcitrate patients; nothing is easier than to vary the 
doses according to effects obtained, and they are within the reach of any 
purse. The efficacy of cold baths is incontestable; their application 



40 PARATYPHOID FEVER 

presents the greatest difficulties in private practice, they require incessant 
supervision, and expose to the danger of brusque chilling that may induce 
pulmonary congestions. Phenol we have never employed; it is difficult 
to take by the mouth and should be used in enemas; it is then almost 
impossible to judge of the quantity absorbed, but part escapes in the 
stools. For these reasons the alkaloids seem to us to merit the preference 
in typhoid fever." 

PARATYPHOID FEVER 

The study of the typhoid group has revealed the presence of fevers 
closely resembling true typhoid, but differing in that they do not respond 
to the Widal test. From these a bacillus has been isolated which gives 
a prompt reaction with the diluted blood of the patient but not with that 
of those suffering with true typhoid which reacts to the Widal. 

The new bacillus belongs to the colon group, is motile, has flagella; 
does not liquefy gelatin, differs from the colon bacillus in not coagulating 
milk, fermenting glucose, and producing alkali in the culture media. 
(Meltzer, Med. Record). 

Close relations exist between this organism and a group of bacilli 
isolated from beef that caused epidemic poisoning in Germany. 

The disease has been recognized as forming a small part of typhoid 
epidemics in several countries, about 8 per cent of the cases being para- 
typhoid. No special predisposition has been ascertained, as to age, 
sex, etc. 

As compared with true typhoid, the incubation of paratyphoid is brief; 
the attack is abrupt. It begins with malaise, dullness and apathy, severe 
headache, diarrhea at first, followed by mild constipation, and fever 
rising rather rapidly to 104 . The slow pulse, enlargement of the 
spleen, rose spots, bronchial irritation, diazo reaction, epis'taxis, intes- 
tinal hemorrhages, and in one case an osteomyelitic abscess developing 
as a sequel, show the close resemblance to the history of typhoid fever. 
Nausea and vomiting are sometimes early manifestations (French). 

Sometimes chilly sensations and abdominal pains are early symp- 
toms. A dull flush appears over the malar bones. The tongue is coated, 
sometimes dry, sordes appear, the abdomen is distended and tender, and 
boils and abscesses may form. There are no special blood changes or 
leucocytosis. 

The course is irregular, ending by lysis or by crisis, with short convales- 
cence. Relapses are rare, complications common. The prognosis is 
better than that of true typhoid, and very seldom has a recognized case 
proved fatal. 



ROCKY MOUNTAIN SPOTTED FEVER 41 

The diagnosis is difficult, because some cases are probably multiple, 
the Widal reaction showing the presence of typhoid, but examination of 
the blood, feces and urine disclosing the presence of the paratyphoid 
bacillus also. 

The treatment is that of typhoid fever. Meltzer unintentionally fur- 
nishes the following strong argument in favor of the use of intestinal anti- 
septics: "AH will agree that the presence of a few typhoid bacilli in the 
intestines will not always cause typhoid fever. It has been shown that 
the intestines of the normal human being contain sometimes typhoid 
bacilli, and probably contain often enough some paratyphoid bacilli. 
If these are small in number and not very virulent, they will probably 
bring no harm to their host, and sooner or later will perish by the over- 
growth of the saprophytic inhabitants of the intestine. And even if some 
of their number succeed in penetrating the epithelial layer and entering 
the circulation, they will meet there their destruction from the bacteri- 
cidal forces normally present in the blood." 

From this we see that the clinical advantages accruing from the use 
of the intestinal antiseptics are fully explicable on the latest and most 
approved conclusions of the laboratory. 

It is to the interest of accuracy in diagnosis that these cases shall be 
recognized, even if the treatment is practically identical; especially since 
there seems to be a strong temptation to utilize paratyphoid fever as a 
means of explaining away such aborted typhoids as the clinician can not 
be otherwise "bluffed" out of. Usually the assumption is purely gratui- 
tous, there being no attempt to demonstrate its verity. But even if these 
abortive cases were shown to be paratyphoid we would have the added 
difficulty of explaining why one disease produced by a member of so 
closely allied a group of microorganisms should be abortable, and maladies 
caused by other members be incapable of similar modification. 

The more we study nature, the less disposed we are to draw hard and 
fast lines, or to say that things "can not be." Typical cases shade off 
at the margins into atypical, and we finally come to those which simply 
can not be certainly classified on either side. Positive assertion usually 
indicates moderate knowledge and limited exercise of reasoning faculties. 

ROCKY MOUNTAIN SPOTTED FEVER 

This fever has been found prevailing in several sections of the moun- 
tain country, in western Montana, Idaho, Nevada and Wyoming. The 
limits of latitude are the 40th and 47th parallels; of elevation 3,000 and 
4,000 feet. It is a disease of spring and early summer, and affects per- 



42 MOUNTAIN FEVER 

sons much in the open air. Males are therefore most affected, and adults, 
but occasionally an infant is seized, or an aged man. 

Anderson, from whose investigations our knowledge is mainly derived, 
traced the malady to a parasite, the Pyroplasma hominis, closely resem- 
bling that causing Texas fever in cattle. It is found in the red blood 
corpuscles, and is transmitted to man by the bite of ticks infesting this 
region. 

The incubation lasts a week, more or less. Malaise and chilliness 
may be felt part of this time. The attack commences with a chill, fol- 
lowed by fever of continuous type with slight morning remissions, reaching 
in fatal cases 104 to 106 F. The course extends from eight to fourteen 
days. The decline is gradual. There is pain in the back, loins and 
muscles, difficulty on attempting to move the limbs, epistaxis during the 
second week, the tongue heavily coated at the center and base while its 
edges and tip are red. Nausea, vomiting and constipation are the rule. 
The eyes redden, becoming yellowish later. The urine is scanty, red, 
containing albumin and casts. Respirations are. increased to 30 or even 
60 per minute and bronchitis may develop during the first week. The 
pulse is weak and faster than the fever would indicate. The liver and 
spleen enlarge. The pupils react normally, the mind is clear. 

A characteristic eruption appears on the third or fourth day on the 
wrists and ankles, spreading to the arms, legs, forehead, back, chest and 
abdomen, in the order named. The spots are bright red, up to the size 
of a pea, becoming dark or like petechias in grave cases; they commence 
to fade near the end of the first week and gradually disappear by the end 
of the attack. 

Many red blood cells are destroyed during the attack, the white cells 
increasing slightly, the hemoglobin falling to 50 per cent. 

The diagnosis involves the discrimination of cerebrospinal meningitis, 
typhoid fever, purpura, and peliosis rheumatica. The prognosis is grave, 
the mortality in some districts reaching 90 per cent. Death occurs during 
the third week, sometimes from complications such as pneumonia. 

No distinctive treatment has been devised. Anderson advised quinine 
hydrochlorate hypodermically. The general principles of fever treatment 
should be applied, and the symptoms met as they are presented. 

MOUNTAIN FEVER 

When residents of lower districts first betake themselves to elevated 
regions they are apt to sutler from a train of symptoms to which the above 
designation has been affixed. The first symptom is usually vertigo, 



TYPHUS FEVER 43 

with quickening of the pulse, some difficulty in respiration, a sense of 
fullness or oppression in the chest, swimming sensations, often nausea 
or vomiting, headache, and moderate fever, the temperature reaching 
about ioo° F. Thirst is marked, the appetite lost. These symptoms 
are apt to be aggravated by apprehension and may be distressing. Debility 
is manifested whenever the patient attempts such physical exercise as 
was easy in the lower levels. Epistaxis is not uncommon, and bronchial 
hemorrhages sometimes occur. The nervous unrest may increase and 
become serious enough to compel the patient to return to the former home. 
This is especially the case with women. In two cases the writer has 
known progressive paralysis to supervene, resulting in death even after 
descent to low lands. It is true, the disease may have been implanted 
before ascending to the hills, but both patients attributed the malady 
to that cause. 

Milder forms subside if the patient is restricted from overexertion and 
reassured. Oxygen inhalations may give immediate but temporary 
relief. The milder, non-tensile heart-tonics are useful, such as cypripedin, 
scutellarin, cactin or adonidin; either to be given in small and frequent 
doses till relief follows. If the debility is marked we may even resort to 
sparteine. When patients are susceptible to hemorrhages they should 
take time to ascend, limiting their upward trend to 1,000 feet per week, 
and remaining at each elevation till fully acclimated. Disregard of this 
warning has cost several of the writer's patients their lives. In all cases 
the exercise should be limited until the patient has learned to estimate 
his adaptability to the elevation. Many persons are so stimulated by the 
fresh, light air that they indulge in excessive physical work, until they 
suffer — and then they blame the climate. 

The term mountain fever was formerly applied to a malady now 
recognized as true typhoid. 

TYPHUS FEVER 

Typhus is the ship, jail, camp, spotted and hospital fever of Europe, 
occupying there something like the place typhoid does in America, as the 
common form of continued fever. But under the influence of modern 
hygiene it has become rare, so that now it is almost obsolete. In America 
typhus has never gained a foothold, though repeatedly brought here from 
Europe. Sporadic cases appear sometimes which can not be traced to 
any source, so that Murchison believed it might be developed sporadically. 
But to say that we do not know whence came an infection is far from 
indicating that there is no infection. In 1^92-3 the writer went to New 



44 TYPHUS FEVER 

York to study the cases at the hospital on North Brothers Island, brought 
to the port on the steamer Massilia, an opportunity rarely enjoyed by 
American physicians. 

Typhus is a highly contagious fever, physicians and nurses being 
particularly prone to attacks. Crowding increases the liability to the 
disease and the virulence of the attacks. The contagium clings long to 
the clothing and furniture. The vital cause has not yet been determined. 

The anatomic changes are due to the intense fever, consisting of gran- 
ular degeneration of the muscles, especially the heart; the blood is dark 
and fluid, the liver swollen and soft, the kidneys, spleen and lymph follicles 
enlarged. There is no ulceration as in typhoid. Bronchitis and hypo- 
static congestion are features of both. On the skin is the rash. 

The incubation lasts twelve days or less. There may be no symptoms 
during this period, or the ordinary discomforts of all infections. The 
invasion is abrupt, with a chill or rigors, fever, headache, aching back 
and legs; debility quickly supervening, fever reaching the maximum in 
two days; pulse full and fast, tongue white, soon showing dryness; the 
face flushed and the eyes congested. The face is more stupid even than 
in typhoid. Vomiting is usual. Delirium may be quiet, stupid or mani- 
acal. Cough is common. 

The rash appears about the third to fifth day, on the abdomen and 
chest, the face and extremities next; all of it coming out within a few 
days, not as with typhoid in crops. The skin is mottled finely a dusky 
red, and rosy papules appear which become petechial; dark to black, 
not disappearing on pressure or after death. Sudamina are uncommon. 
Some attribute to this fever a peculiar odor, and it was once held that 
inhaling this odor marked the infection of the one who inhaled it. The 
skin is dry. 

In the second week the symptoms much resemble those of the third 
week of severe typhoid. The patient lies in a stupor, fever high, pros- 
tration great, eyes half closed, delirium muttering, pupils contracted, 
and conjunctivae injected. The pulse is weak and rapid, the cheeks 
flushed. Coma vigil, subsultus and carphologia are usual; the tongue 
dry, brown and covered with sordes; breathing fast and shallow, the heart 
feeble. Death may occur now from debility, or crisis at the end of this 
week, the patient waking from real sleep, free from fever and restored 
to consciousness. There may be a profuse discharge of urinary solids, 
the urine being turbid. 

The fever goes about a degree higher than in typhoid, the stupor is 
more profound, the prostration greater than in average cases. The morn- 
ing remissions are less decided in typhus. Prostration comes much 



RELAPSING FEVER 45 

sooner in typhus. There is more delirium. Slight leucocytosis occurs. 
Albuminuria is usual, with an increase in the urea and uric acid, and 
a decrease in the chlorides. Nephritis is rare. 

Epidemics vary greatly in their virulence, and there are all grades 
from mild to foudroyant. Complications are bronchitis, pneumonia, 
pulmonary gangrene, noma, gangrene of the toes, nose or fingers, menin- 
gitis, paralysis, septic suppurations and hematemesis. One of the writer's 
cases lost an eye from perforating ulcer. 

The prognosis closely follows that of typhoid. The young bear the 
malady better than the aged. Death near the end of the second week 
occurs from toxemic debility; later, from pneumonia. 

The diagnosis from typhoid is made by the epidemic prevalence, the 
decisive onset, the petechial rash, early prostration, absence of abdominal 
symptoms, and earlier stupor. 

Cerebrospinal fever and malignant smallpox and measles sometimes 
resemble typhus at first, but the course soon clears up the doubts. In 
many cases the diagnosis is difficult or impossible for a time. 

The treatment is that of typhoid in all respects. Keep the bowels 
empty and aseptic; sustain the heart; feed frequently, with small doses 
of easily digested but richly nutritious food; give plenty of water; and 
keep the mouth clean. Treat the symptoms as they arise. 

The lesson of lessons as to the treatment of the typhus fevers was given 
in the celebrated epidemic at the New York quarantine: The officers 
of an infected ship were cared for in a house, and one-half died; The 
commoners were treated in a shed, with a roof and three sides, the other 
open. So flimsy was the shelter that a rain-storm saturated the fortunate 
patients. All recovered. 

Burggraeve thus epitomizes his treatment: Keep the digestive tract 
clear by the use of saline laxatives; sustain the strength with strychnine; 
combat the fever with aconitine; establish diuresis with digitalin; prevent 
a return with quinine arsenate or ferrocyanate; act on the digestive func- 
tions with quassin and soda arsenate: reconstitute the blood with iron 
and cinchona; and adopt a nourishing regimen. 

C. D. Ussher, of Van, Turkey, says that in this fever calcium sulphide 
comes pretty near being a specific as to prophylaxis and cure. 

RELAPSING FEVER 

Relapsing fever appears in company with typhus, so that each epidemic 
is composed of the two, in varying proportions. The hygienic conditions 
giving rise to the one apply usually to the other. It is less contagious 



46 MALARIA 

than typhus, is transported on clothing, and one attack does not confer 
immunity. The specific cause was discovered by Obermeier, in a spiro- 
chete from three to six times the length of a red corpuscle, a spiral fila- 
ment to be seen moving among the red cells during a paroxysm. In the 
intervals these are replaced by small shining bodies thought to be spores. 
Inoculation with blood taken during the paroxysm has produced the 
disease in men and in monkeys, and blood from a bedbug has also pro- 
duced it in a monkey. 

There are no characteristic anatomic changes. In fatal cases the 
spleen is large and soft, the liver, kidneys and heart show cloudy swelling. 
Infarctions may be present. The marrow has been found hyperplastic. 
Ecchymoses are common. . 

The incubation may last a week; how much less is uncertain. There 
is an abrupt invasion, with chill, fever and intense back- and leg-ache. 
Convulsions, nausea and vomiting are more usual in the young. Fever 
rises even to 104 F. the first evening. The pulse goes to 120 or more. 
Delirium comes early. Sweating is common. The spleen enlarges soon. 
In some epidemics the force of the attack is exerted on the stomach, with 
jaundice. The bowels are rarely affected. Cough, herpes, petechias 
and miliary vesicles sometimes appear. Leucocytosis is usual. Crisis 
comes within a week with profuse sweating, diarrhea or urinary turbidity, 
great fall of fever, and in the aged or feeble with collapse. After a week 
of convalescence the relapse occurs, lasts a week, and again there is crisis. 
Even a fifth relapse has been reported, each shorter than the preceding. 
Convalescence is then tedious as the debility is profound. 

The prognosis is much better than in typhus, the mortality being about 
4 per cent. It is more dangerous to the aged and debilitated. Pneumonia 
is the most frequent complication; nephritis, hematuria, rupture of the 
spleen, hematemesis, pareses, ophthalmia and in pregnant women abor- 
tion, are rarer. The case can only be distinguished at the onset from 
mild typhus by examination of the blood. Later, the relapses make the 
diagnosis clear. 

The treatment is that already recommended for typhoid and typhus. 
The probability of collapse in the aged at crisis must not be forgotten. 
No reports have yet appeared on the effects of alkalometric treatment 
in this malady. 

MALARIA 

Malaria has been greatly restricted in recent years by the drainage 
of low lands and cultivation of river bottoms. But the cause still may 
exist in the soil and display its activity when circumstances favor it: Some 



MALARIA 47 

years ago a deep excavation was made in Port Richmond, Philadelphia, 
for a sewer, and as each square was opened up the writer had several 
cases of malaria shortly after the deeper layers of the soil were laid bare. 
There had been no malaria there within the memory of old residents. 

Throughout the southern coast states and along the Mississippi Valley 
malaria still prevails extensively; but in southern Illinois and Indiana, 
notorious as its chosen habitat, it is but a shadow of its former prevalence. 
The resident of "Egypt" no longer takes his daily quinine as a matter 
of routine. In Chicago the writer recognized cases of malaria during a 
wet fall, in the low-lying sections on the south side, in 1894, but has seen 
none since. The opening of work on the Panama canal will render us 
more familiar with the graver forms of malarial intoxication, the valley 
of the Chagres river having been long notorious for them. 

Plasmodium Malariae: — This organism is the principal cause of disease 
and death in the tropical and subtropical countries of the globe. There 
is no reasonable doubt that it is the cause of malaria. Manson thus 
sums the evidence: 

The plasmodium is always associated in the blood with the clinical 
phenomena of the disease. 

Malarial fever at some time in its course is invariably associated with 
the plasmodia in the blood. 

The phases of malarial fever bear a definite relation to the phases of 
Jhe life-cycle of the parasite. 

The absolutely characteristic features of malarial disease — melanemia 
and pigmentation — are fully accounted for by the melanin-forming prop- 
erty of the plasmodium. 

Intravenous injection of blood containing the plasmodia is followed 
after incubation by malarial fever, the plasmodia appearing in the blood 
of the person so injected. 

Quinine causes the cessation of the malarial disease and at the same 
time causes most phases of the plasmodium to disappear from the blood. 

In mosquitoes that have imbibed malarial blood the evolution of the 
parasite may be traced till the germs are found in the salivary glands 
and secretion. 

If after due incubation such a mosquito bites an uninfected person 
he will in due time exhibit the symptoms of malaria and the plasmodia 
may be found in his blood. 

The malarial plasmodium belongs to the Sporozoa and is closely allied 
to the Coccidia. For a portion of its life it is an intracellular parasite, 
inhabiting the human red blood cell. Other vertebrates are infected by 
similar but distinct parasites. 



48 MALARIA 

Malarial blood an hour before the paroxysm shows the parasite as a 
pale disc in some of the red cells, dotted with pigment granules. These 
collect into groups or radiating lines, then into two central masses, around 
which is the pale protoplasm in segments, gradually forming round spores. 
The corpuscle breaks down and liberates these spores with the pigment, 
which float off in the blood-stream. Many spores and the pigment are 
taken in by the phagocytes, but some escape and penetrate other red 
cells. Here the parasites exhibit active amoeboid movements, and grow 
at the expense of the hemoglobin, which they assimilate with their pale 
protoplasm and melanin granules. The amoeboid movements cease as 
the parasite fills the cell, just before sporulation. 

Staining with methylene blue, the spore shows a minute deeply tinted 
nucleolus, an unstained vesicular nucleus; and a lightly tinted proto- 
plasmic covering. After entering the red cell the nucleus and proto- 
plasm are larger, the nucleolus, sometimes double, lies eccentrically in 
the nucleus, the appearance having been compared to a small blue signet 
ring sticking to the blood cell. As it grows to maturity the nucleolus 
disappears and the nucleus becomes indistinct, its elements forming 
numerous nucleoli about which the protoplasm is arranged to form the 
new spores. 

The plasmodia may disappear from the blood as the symptoms sub- 
side, spontaneously or after quinine, and become latent. Where the 
parasites take refuge or what they do there, is unknown. But all elements 
that induce depressed vitality favor the reactivity of the parasites, as all 
that favor vitality, besides quinine, favor latency. Plehm suggests that 
the specks often seen in the red blood cells of Europeans residing on the 
west coast of Africa, who have not had malarial attacks as yet, are the 
lost spores which await a necessary loss of vigor before they can attain 
full development and produce malarial fever. He believes, these "primi- 
tive bodies" multiply in the blood and destroy red cells indefinitely until 
this full development occurs. 

Fresh malarial blood frequently contains flagellated bodies, with long, 
actively moving arms, one to six or more, composed of pale protoplasm 
and melanin, but not in the red cells. Their length is three or more times 
the diameter of a red cell. The body is half the diameter of a red cell. 
Their delicacy and rapid, vigorous movements makes it difficult to detect 
them. Sometimes one becomes detached and swims free in the blood 
serum, with three motions — undulating for locomotion, vibratile when 
coming in contact with other bodies, and coiling just before all its motions 
cease. These bodies develop from two forms of intracellular parasites, 
the crescents and certain plasmodia just previous to the concentration of 



MALARIA 49 

the pigment and speculation. They are never seen in freshly drawn 
blood but only after the slide has been mounted ten to thirty minutes or 
more. 

The crescent bodies have a defined shape, blunt-pointed crescents, 
probably a delicate limiting membrane, needles of melanin near the center 
and a peculiar line beginning near one end on the concavity and passing 
like a bowstring to the corresponding point near the other end; supposed 
to be the remains of the red cell in which the parasite develops. Two 
sometimes develop in one corpuscle. The pigment may be scattered, 
or concentrated, or there may be vacuoles; corresponding to the age of 
the crescent as young, mature or decaying. The pigment in the first 
alone exhibits some motion. In the first the stain takes uniformly, in the 
second bipolarly. Two nucleoli may be found at the center. Mannaberg 
looks on the crescent as a syzygium, from union of two amoebae in one cell. 
Bastianelli finds in it a sexual conjunction, and says the male protoplasm 
stains more deeply than the female. The young form may be recognized 
in the spleen and marrow the fourth day of the disease, as minute, highly 
refringent amoebae; rarely in blood from the surface of the body, where 
the second form is found a week after the first attack. 

The flagellated body may be sw r allowed by a phagocyte; if not, the 
flagellar continue in active movement for an hour, then curl up and fade 
away. If the flagellar get loose the remains of the body assume a passive 
spherical form. 

In another form of the malady certain intracorpuscular parasites, 
only differing from the rest by the greater activity of the pigment, emerge 
from the cell without sporulating, violent motion within the parasite 
follows, and flagellar are suddenly projected. The formation of flagellar 
is favored by the access of air or water. 

Since the flagellated body only develops outside of the human body, and 
the plasmodia are in the body always enclosed in a blood-cell and do not 
leave the body by any excretory door, Manson deduced the theory that they 
must be removed from the human body by some blood-sucking animal; and 
the mosquito of some particular species, inhabiting the malarial regions, 
operating at night, etc., best answered the requirements. Ross first showed 
that when blood containing malarial crescents was taken up by the mos- 
quito the formation and detachment of flagellar was very active. Next he 
found malarial parasites imbedded in the stomach walls of such mosquitos. 
In the next place he found that if a particular species of mosquito is fed on 
blood from birds infected with proteosoma (a closely allied species of 
parasite), the parasite entering the insect's stomach wall and there develop- 
ing spores, these enter the venosalivary gland and the insect is then capable 



50 MALARIA 

of infecting other birds by its bite. By observations on Halteridium, 
another of this parasitic group, MacCallum found that the function of the 
flagellae is to impregnate certain granular crescent-derived spheres, which 
then become " beaked and traveling vermicules." Grassi showed that 
several species of Anopheles, especially Claviger, is the special host of the 
human malaria parasite. He traced the crescent-forming and certain benign 
parasites through the mosquito, and induced malaria in man by the bites of 
infected mosquitos. Every step of these observations has been abundantly 
confirmed by many others. There is no room for doubt thatthe Anopheles 
conveys malarial disease to man when herself infected by the parasite. 

In the Anopheles the crescents form hyaline and granular spheres; the 
former emit rlagellae, which separate and seek energetically by boring and 
butting to force their way into the granular spheres. One enters at a 
papilla that seems to rise to meet the flagellar, causing much disturbance 
in the sphere, and then disappears. No other flagellae can force an entrance. 
The sphere then gradually alters in shape to a wormlike form, the pigment 
gathering at the blunter end, and then begins to move about, the sharp 
end first. This traveling vermicule penetrates the wall of the insect's 
stomach, lodging among the muscular fibers. Here it grows rapidly and 
protrudes from the stomach wall. Meanwhile the contents have divided 
into many little bodies covered with spines like a porcupine, which are 
left free by the disappearance of the spheres. These sporozoites are in 
about a week discharged into the stomach of the mosquito. They thence 
pass into the veneno-salivary glands, from which a duct carries them to the 
bases of the mosquito 's proboscis. If this mosquito bites a human being 
the sporozoites are injected into the blood, where they multiply, and in 
about ten days their descendants appear as the malarial parasites of the 
type originally seen. 

The complete cycle of the parasite therefore begins with its entrance 
into the blood as amcebulae; maturing into sporocytes or gametocytes; 
sporocytes dividing into spores which enter fresh blood cells as amcebulae, 
completing the endogenous cycle and providing for multiplication within 
the animal body; gametocytes belong to the exogenous cycle passed in the 
mosquito, and are male hyaline or female granular spheres; the male emits 
microgametes or flagellae, one of which detaching enters the single macro- 
gamete which constitutes the granular sphere, the union producing a 
mobile zygote which passes to the mosquito's stomach, where it develops 
and divides into zygotomeres and residual bodies. The zygotomeres are 
converted into blastophores with zygotoblasts (sporozoites), which are 
discharged into the saliva and being carried into the blood of a man develop 
into amcebulae and a new cycle begins. 



MALARIA 51 

There are certain facts that seem to indicate that there is yet an undis- 
covered phase of the life of the parasite. In some districts in Africa the 
malaria has rendered the life of a man there impossible, yet malaria remains. 

Men who open up the soil for various excavations are specially liable 
to become malarious, yet the mosquito does not seem to have anything to 
do with such workers rather than with others. The parasite may be 
capable of infecting some other animal than man; or it may pass directly 
from one mosquito to another. Or, there may be some form in which the 
parasite may lay latent in the soil or the w r ater of infected localities until 
it is taken into the bodies of its hosts. But this is simply a conjecture. 
Grassi claims that malaria is only contracted by man from the bite of the 
mosquito; and that the mosquito only becomes infected by biting a malarial 
man. Which began the row is as difficult to settle as the origin of the first 
egg — or chicken. We can only say that up to date no other method of 
infecting man with malaria than by the mosquito has been proved. 

The common mosquito that infects our houses is the Culex, w r hich has 
not been shown to carry disease as yet; that which bears the malarial 
infection being some species of Anopheles. Of this genus four species 
have been found to be infected, the principal one in Europe and America 
being A. claviger or maculipennes. The ova are laid in natural pools or 
sluggish streams, in masses of three or four, adhering to weeds; the active 
larvae feed on algae, come to the surface to breathe with body parallel to 
the surface and when disturbed glide away tail first with skating movement. 
The mature insect has maxillary palpi nearly as long as the proboscis, 
each with five segments, the wings are usually spotted, and when at rest 
the body of the insect is at a wide angle with the surface. Only the female 
sucks blood — the male is harmless and inoffensive. His feathery antennae 
give him the popular name of " wooly-head. " 

The limits of this work will not permit of detailed description of the 
methods employed to detect the malarial parasites in human blood. The 
reader will find this excellently described in Manson's work on Tropical 
Diseases. 

Whether there are several species of malarial parasites or one taking 
different forms, is not yet settled; but the correlation of biologic studies 
and clinical phenomena has shown five distinct types of the disease, corre- 
sponding to five variations in the parasite. Two are termed benign, one 
with a cycle of 72 hours, the other with one of 48 hours, causing the milder 
quartan and tertian fevers. 

Of the malignant forms there are three, one pigmented with a 48-hour 
cycle, another pigmented with a 24-hour cycle, and an unpigmented form 
with a 24-hour cycle. The benign do not form crescents; the malignant do. 



52 MALARIA 

The old distinction between intermittent and remittent forms being based 
on non-essential characteristics may as well be dropped. If all the parasites 
mature at once the attack is intermittent; if some mature at one time and 
others at different times the case will be remittent. Two or three broods 
of the same or different forms may produce the complicated affections 
described by the older writers. 

An attack of intermittent fever is made up of paroxysms recurring in 
24, 48 or 7 2 hours. During the incubation there may be a sense of weakness, 
stretching and yawning, aching bones, headache, anorexia, and curious 
sensations of cold in the back. Slight fever may be present. The patient 
feels " bilious. " When the chill occurs the sense of cold spreads over the 
whole body, the patient is cold, pallid, shrunken, "goose-flesh," shivers, 
teeth chattering, cyanotic, and often vomits freely. The skin is cold but 
the internal temperature rises several degrees. In children a convulsion 
may replace the chill. This stage lasts from ten to sixty minutes. In 
infants under a year there is no shivering but the child becomes cold and 
cyanotic, and lies quiet, so that the parents fear it is dying; and this may 
last several hours, gradually subsiding during the afternoon. The pulse 
is tense and wiry; the fingers shriveled and icy cold. 

The cold shoots in the back begin to be mingled with needles of heat, 
which gradually replace the cold; the cutaneous spasm relaxes, the pulse 
becomes full and bounding, the skin reddens and now seems swollen, 
the head throbs painfully, the covers before clutched tightly are now 
thrown off, breathing is rapid and the temperature rises higher, to* io5°F 
or more. The thirst is great and the stomach may be still disturbed. 
Delirium sometimes occurs. This stage may end in half an hour or last 
four hours. 

Sweating begins on the face and quickly extends over the entire surface, 
from which perspiration streams. The fever falls fast, the headache and 
gastric distress subside, and the patient is immensely relieved, often falling 
asleep, though quite weak. The temperature falls below normal as a rule. 
The duration of the whole paroxysm varies, but is usually between six and 
ten hours. 

The cold stage is one of intense cutaneous vasomotor spasm, and 
the urine secreted is abundant and pale, with low specific gravity. During 
the hot stage this spasm is relaxed and the excretion is febrile, scanty, 
red and concentrated, sometimes albuminous. Urea is increased during 
the chill, as are chlorides; phosphates decreased but excreted freely during 
sweating when the urine may appear muddy. Urea excretion begins to 
rise before the chill, subsiding when the hot stage begins but remaining 
high throughout all the stages. Carbonic excretion corresponds with urea. 



MALARIA 53 

This increased urea excretion recurs even when the paroxysm is pre- 
vented or jugulated by quinine (Ringer.) Bile is often present in the 
urine, or Gubler's brown pigment; sugar occasionally. 

The spleen enlarges during the chill, and its edge may be felt below the 
margin of the ribs.- This subsides after the paroxysm, but less completely 
after each, so that its permanent enlargement is a feature of chronic malaria. 
Each paroxysm destroys some red blood cells, and a corresponding degree 
of anemic cachexia is induced — a little more after each chill. 

Two-thirds of the attacks begin between midnight and noon. About 
10 a. m. is the time chills are usually expected. Quite often the attack is 
atypical, being represented by chilliness, headache, nausea, depression, 
or febricula. In a dangerous form there is fever up to 104, but little else 
to warn the patient of danger until pernicious symptoms supervene 
suddenly. Or there may be vomiting and weakness, or neuralgia, with no 
chilliness. In fact, in malarious districts the physician learns to detect 
malaria in all manifestations recurring periodically. 

During the intermission there may be no symptoms beyond weak- 
ness, and the patient may even attend to his usual work on his 
"well days". Herpes about the mouth is frequent, also cough and 
bronchial irritation. 

If the attack occurs every day at the same hour it is known as a quo- 
tidian; if on alternate days it is a tertian, the recurrence completing a cycle 
of three days; while a recurrence on each third day constitutes a quartan 
ague. Sometimes the chill occurs a little earlier each time, and at others 
a little later. If they are prolonged until the succeeding paroxysm overtakes 
the incomplete one preceding, it is called subintrant, and if the temperature 
does not entirely fall to normal it is remittent. There may even be no 
remission but the fever continues. Mixed infections and the hatching of 
differents broods may give rise to double tertians or quotidians, or com- 
binations of any of the primary types. 

The stages of the disease are believed to correspond with the phases of 
the parasite's life. As the rigor approaches, pigment concentrates in its 
body and just before and during the chill sporulating bodies are breaking 
up and possibly liberating toxins; during the hot and sweating stages young 
parasites are free in the blood, or have penetrated red cells, and leucocytes 
are disposing of free pigment, while toxins are being eliminated; during the 
intermission many parasites are shut off from the circulation and maturing 
within their hosts, the red cells. But the presence of parasites in the red 
cells cannot be the cause of fever, since they may be found in abundance 
free in the blood during the intermission. The hypothesis that fever is 
due to a toxin diffused when the plasmodia escape from the red cells accounts 



54 MALARIA 

for the remittent and continuous forms, during which sporulating plasmodia 
are found in the blood at all times. 

The parasite of quartan fever has a cycle of 72 hours. It first appears as 
a small round speck on the hemoglobin of the red cells. Its amoeboid 
movements are feeble, and cease when it has become pigmented. The 
arrangement of its large coarse particles of pigment has won it the name of 
" Daisy; " eight or ten particles being arranged around a large central mass. 
Very active movement of pigment characterizes the cells that are to become 
flagellated. This parasite does not enlarge the red cell in which it develops, 
but completely fills it, leaving a narrow rim of hemoglobin. It is more 
easily detected in peripheral blood than the other parasites. The disease 
arising from this form is common in temperate regions, becoming rarer as 
the equator is neared. The paroxysm is well marked, cachexia and anemia 
develop but slowly, it is amenable to quinine. Osier thinks the attack apt 
to cease spontaneously though liable to recur; but Manson considers it 
more persistent than tertians. 

The parasite of benign tertian differs from that of quartan in greater 
amoeboid motility, decreasing till it ceases, when pigment concentration is 
complete; the pigment particles are finer, in incessant motion, mostly 
in the peripheral zone; the red cells containing parasites are much enlarged 
and pale; when segmentation is complete it resembles a bunch of grapes 
with black pigment masses included; the spores are smaller, rounder and 
smoother than the quartan, seldom showing nucleoli unless stained, and 
number from 15 to 26. This parasite is found in temperate and tropical 
lands alike, often occurs doubled, and is probably the most frequent cause 
of quotidian and tertian agues. Its fevers resemble those of the quartan 
except in the shorter cycle. 

The three malignant parasites may be found alone, together, or with the 
two benign forms. The former are much the smaller. Until pigmented 
they are not easily detected. At first the amoeboid movements are very 
active, and as they grow quiet they assume the ring form. More than one 
often attack a red cell, owing to the vast number of parasites. The affected 
cells seem to be retained by the vessels of internal organs and marrow, so that 
they are scarce in blood from the surface. The invaded cells often become 
crenated, folded and quite dark, called by the Italians "brassy bodies." 
The crescents appear about a week after the intracorpuscular plasmodia, 
and multiply for some days, persisting for some weeks after the latter have 
disappeared. Quinine may prevent their development but has no influence 
over them when once formed. They do not cause fever but cachexia. The 
fever these parasites cause is irregular in type, the rigor short, the fever 
prolonged, with more weakness, gastrointestinal disturbance, aching, 



MALARIA 55 

headache, etc. Relapses are frequent, in 8 to 14 days. Many red cells 
are destroyed and cachexia is rapid. Pernicious symptoms may develop 
at any time. The two quotidian parasites, pigmented and unpigmented, 
usually occur together, are very active, annular, and previous to sporulation 
occupy less than half the red cell. They form six to eight minute spores. 
Segmenting forms are found in splenic blood. 

Intermittent malarias occur in cool climates and seasons, and as first 
infections; relapses are apt to be due to malignant parasites and to be 
dangerous. But if a malignant infection is contracted in hot weather or a 
low latitude, relapse may occur in cooler circumstances. Benign first 
attacks are usually intermittent, sometimes remittent; malignant attacks 
are just the contrary. First attacks of newcomers in highly malarial hot 
localities are remittent and severe. Under favorable circumstances some 
remittents run their course to recovery in about two weeks, the plasmodia 
and fever then disappearing together. Possibly when the invasion is not 
too numerous the phagocytes can take care of the sporules as they emerge 
from the corpuscles, and no febrile attacks result. 

Bilious remittent has been recognized as a distinct variety from the 
bilious vomiting, diarrhea, etc., attendant. Hematogenous jaundice 
attends. The anemia is marked, and chronic malarial toxemia is a frequent 
result. 

Typhoid remittent is a much graver affection, with symptoms of the 
typhoid state, low muttering delirium, dry brown tongue, great prostration, 
subsultus, swelling of spleen and liver, and melanemia. Many die. 

In Kelsch's adynamic form are seen stupidity, restlessness, nervous, 
cardiac and muscular depression, great and rapid destruction of red cells, 
jaundice, melanemia, leucocytosis, syncope, hemorrhages, local gangrene, 
sometimes hemoglobinuria. These forms are more apt to occur in con- 
sumptives, syphilitics, alcoholics and nephritics. 

The term 'pernicious' is applied to a group of symptoms appearing often 
in the course of remittents and sometimes following attacks that seem to be 
at first ordinary intermittents. There are two types, the cerebral and the 
algid. Patients residing in highly malarial districts may suffer from a mild 
attack, when suddenly hyperpyrexia and coma set in, the patients dying of 
what is believed to be apoplexy or sunstroke. The fever jumps to any point 
up to 112 , with wild or low delirium, stupor supervening and within one or 
two hours the patient dies comatose. In other cases coma comes without 
fever, or even with abnormal temperature, to break in a critical sweat 
or the patient dies in collapse. Sudden delirium, convulsions, apoplexy, 
paralysis, tetanus and aphasia, may be simulated by these cerebral attacks, 
and when not fatal permanent mental disorder may result. They are now 
attributed to embolism of various cerebral capillary tracts. 



56 MALARIA 

Amblyopia, temporary or permanent, results from obstruction of the 
ocular vessels. 

The algid forms are characterized by extreme coldness of the skin and 
extremities, from vasomotor spasm, with a tendency to fatal syncope. The 
internal temperature is high. Acute gastritis may be present, with incessant 
vomiting, great gastric distress and tender retracted abdomen. Or the 
attack vents its fury on the bowels, with choleraic symptoms, the stools 
containing bile, sometimes blood and mucus. Muscle cramps, aphonia, 
pinched face, shrunken fingers and scantiness of the urine may be present 
and end in fatal collapse. The resemblance to cholera may be close, but 
there is high internal fever, a history of malaria, subsidence of symptoms 
as the hot stage occurs, and bilious stools. In doubt the blood examination 
tells the tale. 

A third algid form takes the semblance of dysentery; and in truth the 
dependence of disease upon malaria is to be kept in mind. The blood 
again furnishes the diagnosis. 

While the preceding attacks occur with the chill, in the syncopal form 
collapse supervenes in the sweating stage, which is excessive. Death may 
follow an attempt at rising, especially in the feeble and cachectic. 

These abdominal forms are probably caused by an accumulation of 
Plasmodia in the mucous capillaries. The sweating may be ascribed to 
the destruction of red-blood cells, or to reaction from the malarial toxin. 
The practician in dangerously malarial districts learns to be on the alert 
as to these maladies, and to be solicitous over irregularities in the course 
of mild attacks, mental disturbance, alteration of knee jerks, restlessness, 
peculiarities of behavior, and other indications of something abnormal or 
unusual. Wetting and chilling, errors of diet, and all causes of vital depres- 
sion, are to be avoided for months after leaving the scene of a malignant 
malarial attack. 

Hemoghbinuric Fever:— This is popularly known as blackwater fever. 
The paroxysm begins with chill, bilious vomiting, jaundice and black urine 
in small quantities. It occurs in the Gulf belt and the West Indies. Manson 
believes that the form he sees, the African, at least, is a distinct disease due 
to a distinct parasite. Even if the patient recovers he is left with intense 
anemia and damaged kidneys, and a strong disposition to recurrence of 
similar attacks, any of which may be fatal. The attacks are more frequent 
in those who have become saturated with malaria during the residence of 
over a year. 

After ordinary malarial attacks, controlled by quinine, the victim has 
one apparently similar, irregular and bilious, with aching in the kidneys, 
liver and bladder; he feels an urgent demand to urinate and finds the urine 



MALARIA 57 

dark, brown or black. Fever continues, with gastric distress, bilious 
vomiting and possibly diarrhea, or constipation. With profuse sweating 
the fever falls, the urine is excreted more freely and gradually pales. The 
skin has been safTron-colored and this deepens for several days. Subsidence 
of the attack leaves behind it profound weakness. Fever may recur in any 
of the classic types or irregularly. Hemoglobinuria may recur or not. 
The urine may be copious or become scantier and gummy until suppressed. 
The worse the attack, the greater will be the gastric distress and vomiting, 
and pain in the back and liver. The worst cases die, from adynamia, 
cerebral or algid symptoms. Sometimes the symptoms resemble those due 
to sudden hemorrhages — jactitation, cold sweat, sighing and syncope. 
Total suppression of urine for some days may cause coma, convulsions and 
syncope, or nephritis with uremia may cause death some weeks after the 
attack has passed off. 

Th e urine on standing separates into an upper layer, clear, very dark 
port-wine tint, and a lower brownish-gray sediment, containing many 
hyaline and hemoglobic casts and granular matter. The serum globulin 
escapes with the hemoglobin as the urine turns nearly solid on heating. 
There are few or no red cells. The albumin gradually diminishes after 
the color has become normal. If death occurs early the kidneys are con- 
gested, the tubules gorged with hemoglobin, the cells with yellow pigment, 
the capillaries with black. After death later from uremia the large white 
kidney is found. The liver is large, soft, dark yellow, with cloudy swelling 
of the cells, which contain yellow pigment. 

This is Manson's account of the African hemoglobinuric fever. How 
far does it agree with the appearance presented by the disease in our southern 
states ? 

The malarial parasites present disappear during the course of hemo- 
globinuria, and it may finally terminate a chronic malaria — a spontaneous 
cure. 

Anatomy: — The loss of red blood corpuscles and consequent anemia 
are out of all proportion to the number attacked by the parasites, for while 
5 per cent of corpuscles affected would be a very high and unusual percentage 
each ordinary chill occasions a loss of 5 to 10 per cent of the corpuscles. A 
pernicious paroxysm may lessen the red cells a million per c. mm., and from 
5 million the count may fall below one million. There is also usually 
a fall in the hemoglobin of remaining corpuscles that may reach 50 per cent. 
Still further, there is a loss of volume of the blood; so that with less blood, 
poorer in cells and these poor in iron, there is reason for the extreme pallor. 
By reduction of the volume of blood it happens that congestion of the spleen 
and liver is less than would be expected, the portal system being empty. 



58 MALARIA 

The loss and its repair are greater in first attacks than in relapses. The 
greater losses from severe attacks are not absolute. 

After death in an acute attack the spleen is found to be enlarged, dark 
and soft, even pultaceous; the liver ditto, the encephalic vessels engorged, 
the gray matter leaden, the marrow dark and congested, and this dark 
congestion may affect the lungs-, kidneys and bowels. 

Pigmentation is pathognomonic of malaria, and malarial blood always 
shows it; also it is found in the endothelial cells, often in leucocytes, forming 
thrombi that occlude vessels, and in the spleen and marrow alone pigment 
is found in the cells of the parenchyma. Intravascular black pigment is 
found only in malaria. 

This pigment is insoluble in strong acids, is altered by potash, and 
quickly soluble in ammonium sulphide. That in the leucocytes is obtained 
from the parasites. In the spleen a phagocyte may contain at the same 
time pigment, parasites, broken hemoglobin and even a number of entire 
cells, mostly containing parasites. One phagocyte may even contain a 
second, and that a third. The pigment is most abundant in the splenic 
vein; in leucocytes and in large white cells. Some of these are also found 
in the liver, but rarely beyond it. More parasites are also found in 
the spleen than elsewhere. After malaria has existed a time pigment 
can also be found in the vessel walls and perivascular lymph-spaces, whence 
it goes to the lymphatic glands for final disposal. Those in the hilum of 
the liver are markedly pigmented in chronic cases. 

These facts show that the destruction of red cells in the blood is but 
small as compared with what is going on in the spleen, marrow, liver and 
elsewhere. The contest in the blood is only skirmishing. 

The black pigment is pathognomonic, but of little importance patho-' 
logically. Kelsch and Kiener describe a pigment ochre also, in the proto- 
plasm of parenchymatous cells generally. It is also found in other diseases 
with great and rapid destruction of red cells. It is insoluble in acids, in 
alkalies and in alcohol. It gives the reaction for iron only when long 
deposited in the tissues. To a certain point the liver can convert hemo- 
globin into bile pigment, the bile being increased thereby; hence the bilious 
symptoms so common in remittents. The yellow skin is probably tinted 
with free hemoglobin and not with bile. When the liver has reached the 
limit of its function of pigment conversion the surplus is stored in the 
parenchymatous cells. This is the pigment ochre. If the liberation of 
hemoglobin be too great for such disposal we have hemoglobinuria. 

This enormous supply of free hemoglobin may be partly derived from 
the red cells, which as we have seen lose a part of their stock. Manson 
suggests that at the chill there is a sudden liberation with the parasites 



MALARIA 59 

emerging from the red cells of a hemoglobin-solvent agent, which may have 
served the purpose of a digestant to the parasite during its intracellular life. 

The red cells are larger than usual, and some megalocytes are present, 
also small dark embryonic forms, and some of irregular outline and indis- 
posed to form rouleaux. In one case not a sound corpuscle could be found. 

In mild attacks the leucocytes are decreased in number until the end of 
the paroxysm; then rise a little till two hours after the chill. The large 
mononuclear cells are greatly increased. In malignant forms the conditions 
are not clear, but in some cases of pernicious attacks there is an increase 
in surface blood, which may even be enormous (Billings). The hemato- 
blasts decline during the paroxysm and rise above normal during the 
intervals (Hayem). 

What causes the fever and its periodic recurrences ? The cycles of the 
parasites, quotidian, tertian and quartan, correspond with phases of the 
febrile paroxysms. The attack of fever coincides with the escape of 
parasites from the red cells. Some toxin then escapes into the blood to 
which the phenomena are to be attributed. The periodic liberation of this 
toxin accounts for the periodicity of febrile attacks and its elimination puts 
a stop to them. 

But why should the entire swarm of parasites develop and escape from 
their cells at about the same moment? Manson attributes this to the 
quotidian periodicity in the rhythm of the physiologic processes of the human 
body. All animals but man are immune against malaria; some men are 
immune; others acquire some immunity by residence in malarial districts; 
the first attack of a newcomer is apt to be remittent or continuous, but as the 
resistant forces of the body increase, they are able to protect the man during 
all the day except the time when the attack occurs. Parasites maturing 
earlier or later than this unprotected period perish, while those maturing 
at this time survive. 

This hypothesis does not commend itself to the writer. Judging from 
the effects of heat in developing all forms of malaria, and the coincidence 
of malignant forms with torrid climes and seasons, it does not seem 
far-fetched to attribute the occurrence of chills at about n a. m. to develop- 
ment of the parasite at that hour by the heat then supplied by the sun. It 
is a tradition of malarial places that sitting in the sun will develop ague. 

Spontaneous recovery proves the existence of a protective power in the 
human body. Such cases are not usual. 

Malarial Cachexia: — This may follow severe or long-continued acute 
attacks, or be developed by long exposure to its cause. The symptoms 
are anemia, an earthy hue of the skin, yellowish eyes, enlarged spleen, and 
in the early stages enlarged liver. Irregular febrile attacks are frequent 



60 MALARIA 

after fatigue, exposure or other causes of lowered vitality. Fever is not an 
essential; in fact, one case coming under the writer's notice was recognized 
as malarial by its persistent subnormal temperature with periodic crises. 
Many residents of malarial regions have enlarged spleens — big bellies and 
thin shanks, dull and depressed aspect, earthy complexion, rough unhealthy 
skin, dark and with patches of pigmentation on tongue or palate. The 
parasites have been found in the blood of a four-months-old babe, and it 
is asserted that infants are born malarious. But Bignani failed to detect 
parasites or pigment in the fetus of a woman who died of a pernicious attack. 
Children early affected are apt to be poorly developed, stunted, and as 
abortion and sterility are usual results the population is repressed. 

Many functional ailments appear in these cachectics, which tend to 
periodic recurrence; such as neuralgias, gastralgias, gastric, intestinal and 
other crises, headaches, palpitation, hiccough, sneezing and various erup- 
tions. Besides their periodicity these affections are controllable by quinine, 
although such maladies are not usually amenable to this remedy. Hemor- 
rhages of all varieties are common in some cases and trifling operations may 
then prove fatal. Gastric and intestinal ails are the rule; dyspepsia, morn- 
ing diarrhea; low forms of pneumonia carry them off. 

If there is on]y anemia with portal congestion the patient may recover 
promptly; if there is organic. abdominal disease the final ending is death. 

The pathology is that of acute forms. Splenic growth- may be enormous, 
the connective hyperplastic, the pulp soft and stained with black pigment. 
This " ague-cake" is diagnostic of malaria, and its frequency tells of the 
insalubrity of the district. The tumor is easily ruptured by a blow. The 
liver may be permanently enlarged by febrile attacks, not by afebrile con- 
ditions. Cirrhosis results in time. When the yellow pigment responds to 
tests for iron it is known as siderosis. There is no tendency to suppuration. 

Similar changes take place in the kidneys; the cardiac muscle degenerates 
and its walls dilate; dysentery, diarrhea, low pneumonia tending to abscess, 
empyema, phagedena, noma, pernicious fever, may occur; splenic leukemia 
is a sometimes remote effect. 

Etiology: — The invasion of the parasites is now established to be through 
the mosquito. All agencies tending to favor the breeding, infection and 
access of these increases the liability to malarial fevers. Manson claims that 
the evidence of an invasion may not appear for months or years after the 
bite. In colder latitudes the connection of malaria with swamps is much 
closer than in the tropics; infection is milder, and active only in late summer 
and early fall. Flats at the base of mountains, waterlogged; deltas of large 
rivers; the pools along dried-up river beds; uncultivated fields and tracts 
just deforested, are often malarial. But elevated, arid, sandy plains are 



MALARIA 61 

sometimes intensely malarial. It is a disease of the country rather than the 
city. Occurring on ships at sea, the mosquito may have been an 
unauthorized passenger. Many peculiarities hitherto inexplicable are 
resolved by the mosquito theory. 

A sustained average temperature above 6o°F is necessary. Altitude 
has no direct effect. Water is essential — best in small pools with no fish, 
as they eat the larvae. Decomposing organic matter is not essential. A 
high level of the subsoil water favors mosquitoes and malaria. Hence 
comes the danger from subsiding floods, or raising the water level by 
engineering works. The overflow of swamps stops the fever — washes out 
the mosquito broods. The mosquito seeks shelter from even slight 
winds, and does not rise more than a few feet from the ground; hence 
transport by winds is not notable. 

A mile between a vessel and land secures the crew. Italian peasants 
secure immunity by passing the night on platforms raised on poles a few 
yards. Trees protect dwellings from swamps behind the trees, by stopping 
the mosquitoes. The infection is most active at night, and the mosquito 
works between sunset and sunrise. The unquestionable facility with which 
malarial infection follows disturbing the soil by digging up streets, etc., 
cannot be explained on the mosquito theory, and suggests that there are 
other methods of infection as yet untraced. But the introduction of malaria 
by infection of the mosquitoes from an infected visitor explains many 
hitherto mysterious outbreaks. Further studies of the various species of 
mosquito are needed. 

Acclimatization — Manson attributes much of the alleged caclimatization 
of residents in malarial districts to the minute care they have learned to take 
of themselves. Some persons are absolutely immune. The negro is less 
liable than the Caucasian, while the Chinese and other dark races are less 
affected than the whites, but more than the negro. The whites of southern 
Europe have not inherited immunity so much as they have learned 
how to live. 

Diagnosis: — The practician in malarial districts gets to see the malady in 
everything. Periodicity and a curative effect from quinine suffice, though 
these are uncertain. In doubtful cases the microscopic examination 
of the blood is infallible. The detection of the Plasmodia or of melanin 
suffices. 

Quinine is useful in intermittents and larval forms but less so in severe 
remittents. It requires time also. Tertian and quartan periodicity occur 
only in malaria; quotidian is less conclusive. It occurs in abscesses of the 
liver; but here the spleen is not enlarged, fever rises highest in the afternoon, 
perspiration is not specially post-febrile, but occurs in sleep; and dysentery 



62 MALARIA 

almost always has preceded the abscess, in which the periodicity is 
quotidian never tertian or quartan. 

Yellow fever and hemoglobinuria are constantly mistaken. 

Yellow Fever: Malaria: 

Sthenic Asthenic 

Violent headache Not so prominent 

Injected eyes Eyes yellow 

Mahogany face Livid, cyanotic or yellow 

Albuminuria marked and increasing Slight if any 
Hematuria rarely True hemoglobinuria 

Spleen and liver little enlarged Enlarged early and greatly 

Epigastric tenderness and burning Not marked 
Vomit white, later black Vomit bilious, rarely blood 

Jaundice late if at all Jaundice early 

Endemic in limited areas Wide and known range 

Pulse slow as to fever Pulse weak or wiry, rapid 

Attacks newcomers Attacks old residents 

The onset of yellow fever is totally unlike any but very rare cases of 
malaria, the urine is scanty to total suppression, and there is an irritability 
of the stomach far exceeding anything seen in malaria. But in some cases 
it seems impossible to make the diagnosis except by the microscopic exam- 
ination of the blood. Does this exclude yellow fever ? Suppose that during 
an epidemic of the latter, persons who are malarious are seized with 
yellow fever ? 

In cerebrospinal meningitis we have stiffness of the neck, and the erup- 
tions. Urethral fever, gall-stones in the very young, renal suppuration, 
lymphangitis, tuberculosis hectic, ulcerative endocarditis, Mediterranean 
fever, pernicious anemia with splenic leukemia, visceral syphilis, rapidly 
growing sarcoma, hysteria, and other affections may present quotidian 
paroxysms resembling ague. But the spleen is not always enlarged in these, 
the crises are always quotidian, never tertian or quartan, quinine has no 
decided beneficial effect, and each has its own special symptoms; so that 
even without resort to blood examination it can usually be diagnosed. 

In doubtful cases the microscope and Widal's test are necessary to 
separate malaria from typhoid fever. When typhoid attacks a malarial 
subject there may be several well-marked chills at the beginning, the typhoid 
symptoms gradually becoming manifest. Pernicious malaria may so closely 
resemble sunstroke, apoplexy, dysentery, cholera, puerperal fever, pneumo- 
nia, aphasia, etc., that the microscope alone will distinguish the real malady. 

Five minutes suffice to secure a certain diagnosis; and with this to direct 
a certain therapeutics, promptness, strength and boldness in treatment will 



.MALARIA 63 

give results that will seem miraculous to the feeble therapeutist who timor- 
ously experiments with uncertain weapons after a tentative diagnosis. 

TreBtment: — One of the greatest advances ever made by therapeutics 
was the use of Peruvian bark for malarial diseases. The dose was an ounce, 
and this was given in liquor or wine. If the stomach could be induced to 
retain it, the benefit was greater than had been derived from any previous 
medication. But what a dose! 

In time pharmacy progressed to the production of an extract, getting 
rid of 450 grains of useless dirt, and reducing the dose to 30 grains. To 
this day there may be many devotees of the "ague stick," who cling to the 
cinchona extracts, even when deprived of quinine. The farmers of some 
sections carry this in their pockets and whittle off a chunk as their needs 
dictate. But all fetiches lose their sway as knowledge spreads, and in time 
*he medical profession suffered itself to be persuaded that there was no 
benefit to be derived from an indeterminate quantity of inert coloring 
matter and resin; and finally quinine has completely replaced the older 
preparations. 

Many attempts have been made to find a substitute, but to no purpose. 
The laity and the profession alike place their faith in it. There is the more 
reason that we should determine exactly what quinine will do and what 
are its limitations. Too much must not be expected of even so good a 
servant. 

Manson says that a paroxysm once begun cannot be cut short by quinine; 
which he advises in the sweating stage, ten grains, with five grains every six 
to eight hours for the next two or three days. This is almost certain to 
prevent the third attack of intermittent. An aperient and rest in bed are 
invaluable aids, in cachectics and obstinate cases. When the fever has 
gone he gives iron and arsenic, with five to fifteen grains of quinine every 
five to seven days for six weeks. If the crescents are present he gives once 
a week a saline laxative and fifteen grains of quinine; iron and arsenic on 
the other six days. Too large doses of quinine may cause deafness — per- 
manent — amblyopia, collapse, or fatal syncope. Children under a year 
should take half a grain at a dose. If the malady resists the doses ad- 
vised, the diagnosis should be revised. 

As quinine has caused miscarriage it should be given to pregnant 
women in minimum doses, three grains every eight hours for two days. 
There is more risk of miscarriage from ague than from this much quinine. 
The plasmodia awake to activity in the puerperal state so that during or 
after labor several five-grain doses should be given. 

Quinine is best taken in solution; pills and tablets are apt to pass through 
the bowels undissolved if the tongue is foul and digestion disordered. It 



64 MALARIA 

would be well to substitute the hydrochlorate for the universally employed 
sulphate, the former being much more soluble in water. Manson advises 
to give quinine to children in a tablespoonful of milk, first greasing the 
mouth with butter. Quinine may be given by the rectum a few times, but 
it soon becomes too irritable to retain the drug. 

In many cases it is best to inject the drug into the muscles. It is painful 
and may cause abscess, but the advantages outweigh these drawbacks. 
The acid hydrochlorate is soluble in less than its weight cf water; the hydro- 
bromate is nearly as soluble. The sulphate may be dissolved by adding 
half its weight of tartaric acid. The hypodermic dose is 10 to 15 grains, 
and in grave cases this may be given every 8 hours. Cleanse the skin asep- 
tically, use sterilized water for the solution, and insert the needle deeply 
into the gluteal or scapular muscles. Not only is this an economic and 
effective way of administering quinine, but by it cases may be cured that 
resist the same remedy by the stomach. But the asepsis must be per- 
fect — tetanus has followed injections of quinine. 

In pernicious comatose remittents, where there is no time for other 
methods, Baccelli injects intravenously the following: — Quinine hydro- 
chlorate 1 gram, sodium chloride 0.75 gram, water 10 grams. Of this he 
injects 5 to 7 grams and has reduced the mortality in these desperate cases 
from 1 7 to 60 per cent. 

Warburg's tincture sometimes succeeds where quinine fails. It is a 
powerful sudorific. The coal tars relieve headache and fever. 

How does quinine act ? As it is destructive to free amoebae it may be a 
direct poison to the plasmodia. Some say it stimulates the phagocytes, 
others that it paralyzes them. In man it causes quick disappearance 
of all plasmodia except the crescents. Sometimes it seems to awake a latent 
malaria and bring on a chill — -as do hydropathy, sea-bathing and some 
mineral waters. 

In severe forms such as bilious remittents, we cannot wait for the remis- 
sion, but give fifteen grains of quinine at once. While it acts better after 
the bowels have been cleared out, the time is worth more than is gained by 
waiting for a cathartic. A full dose of calomel may be given with the qui- 
nine, and five grains of the latter every three to six hours till the fever has 
subsided. If bilious, the stomach should be cleared with ipecac or warm 
water before giving quinine. The usual expedients are employed to 
quiet the stomach; but if it will not retain quinine, clear the rectum and give 
30 grains in solution by that route. 

As in all other cases, hyperpyrexia demands the instant and energetic 
employment of cold — ice to the head, ice-water in the rectum, cold baths. 
Quinine should also be injected into the veins or muscles, five to fifteen grains 



MALARIA 65 

every three hours till 30 to 40 grains have been given. But the heat must 
be held at a safe point for four hours, till the quinine has had time to get 
to work. The coal tars are worse than useless (Manson). Use the cold 
bath whenever the axillary temperature reaches 106, and remove the patient 
when it has fallen to 102 in the rectum. Take temperatures every two 
hours and repeat the bath if needed. 

For algid and dysenteric attacks Manson advises quinine and opium; 
ipecac for the latter; or saline and opium. But a hypodermic of atropine 
is so exactly indicated in the algid crisis that it should be given at once, in 
dose enough to send the blood back to the skin. Emetine will supply the 
place of ipecac and be far more likely to stay in the stomach. 

Hemoglobinuria: — Koch agrees with many observers in our southern 
states that quinine is apt to induce this affection. It comes on even while 
the patient is cinchonized. In large doses quinine, being a protoplasmic 
poison, renders hemoglobin unstable and destroys red cells. If this is 
added to the destruction by parasites it may cause escape of hemoglobin by 
the urine. Bastianelli advises quinine if hemoglobinuria occurs during 
a paroxysm, the parasites being found in the blood; withhold it if parasites 
are not found; if given before hemoglobinuria and no parasites are 
found, suspend it; if they persist, continue it. 

Calomel in very large doses is a favorite with many — a teaspoonful at a 
dose. Cases have recovered with neither calomel nor quinine. Quennec 
gave chloroform in 22 cases without losing one; 15 minims every ten minutes 
until some chloroform intoxication is produced, which is then sustained by 
chloral enemas. Tannic acid gr. 15 every two hours for four or five doses 
has succeeded when quinine failed, and especially in hemoglobinuria. 
Give also two doses each on the third and sixth days. Sodium salicylate 
is recommended. When anemia is profound, blood has been transfused 
with advantage. The most scrupulous care must be taken of persons 
who have had an attack of hemoglobinuria; they should go to bed 
at the least sign of fever, keep the skin warm, avoid drafts, and take 
plenty of warm drinks; if parasites are in the blood give quinine five 
grains by hypodermic every four hours, and a large dose of calomel. 
Fatigue, chilling, wetting, and all other causes of vitality depression, 
must be avoided. Cooling off in clothes wet with perspiration is 
dangerous. If the urine grows scanty avoid diuretics, apply heat to the 
loins, give water, and milk as a diet till the albumin ceases. Antipyrin 
and phenacetin are dangerous. 

The place of arsenic is after the fever has been quelled, as a blood- 
restorer. Manson has never seen benefit approaching that derived from 
quinine, from methylene blue, phenol, iodine, anarcotine, analgen 



66 MALARIA 

phenocol, parthenium, ailanthus, chiretta, eucalyptus, or any other drug. 
Capsicum added to quinine seems sometimes to enhance its effects. 

For the enlarged spleen Manson advises counterirritation with iodine 
or hydrarg. biniodide, with salines, quinine, arsenic and iron. Portal 
congestions are benefited by Kissengen or Carlsbad. Cachectics require 
removal to a salubrious residence, and great care to restore the blood. 

The food should be light and fluid; lemons are much relished, boiled 
in water; in convalescence the nutrition should be increased. 

The basis of prophylaxis is the extermination of the Anopheles and 
protection from its bites; drainage and cultivation, or complete flooding; 
filling in of stagnant pools; subsoil drainage with irrigation; good paving 
of towns. Build on high and dry places, yet sheltered with trees, covering 
soil with grass or cement; keep flower-beds away from bedroom windows; 
don 't allow drain water to flow over the surface; don 't keep water unchanged 
in tubs or tanks for mosquitoes to breed in; stock ponds with fish, or throw 
petroleum on them. Eucalyptus trees planted in malarial wet places dry 
the soil, and possibly the emanations keep away the insects. Sunflowers, 
chrysanthemums and other plants are said to be useful in some as yet un- 
known manner. If the soil must be upturned it should not be in the malarial 
season. Local traditions as to unhealthiness of locations should be respected; 
and the abdominal protuberances of the natives bear witness to insalubrity 
of a district. Suspicious water should be boiled before being drank; keep 
on the safe side. Keep in the house at night; sleep as near the roof as 
possible; use mosquito nets, invariably; and especially compel malarial 
persons to use them to avoid infecting mosquitoes. 

The difficulty experienced in winning popular assent to new theories 
is largely due to the inability of men to harmonize the new thought with 
their previous knowledge and views. Possibly this may account in part 
for the skepticism with which so many receive the statement that malaria 
and yellow fever are transmitted to man by the mosquito, and that in no 
other manner can these maladies be acquired by human beings. 

The most stubborn resistance to that part that relates to malaria comes 
from adherents to the water-contamination explanation. The writer 
believes that these two views may be reconciled, and herewith presents the 
case: 

Some years ago, a physician stated that he had attended the laborers 
employed in building the Yazoo railway. So many cases of malaria occurred 
among them that at one time it looked as if the work would have to be 
abandoned; but a complete change occurred when the use of the bayou 
water was forbidden, and that from artesian wells substituted. Thereafter 
no one contracted malaria except those who, despite the prohibition, per- 



MALARIA 67 

sisted in the use of the bayou water. This induced the belief 
that bayou water was the medium by which the cause of the disease 
was transmitted to the men; and this conviction remains firmly fixed 
in the minds of those who had so apparently conclusive a proof of its 
correctness. 

But it is not always wise to accept such surface indications as demon- 
strated truth, for there may be other explanations of the phenomena. If 
the biologic study of the mosquito and of the malarial parasite show that 
only in the body of that insect is the life cycle completed, and the stage of 
the parasite 's development reached in which it can enter the blood of man 
and give rise to the disease, the water infection theory must be incorrect, 
or else some part of the biology is yet unknown. Granting the correctness 
of both series of observations, there seems to be an impasse, but only in 
appearance, for there is a way to reconcile the difficulty. 

For this purpose we will adduce another observation: In Alaska, 
where mosquitoes make men long for winter with temperature far below 
zero, it is found that the voracious insects may be kept at bay by applying 
to the skin a solution of calx sulphnrata, provided the preparation be of 
full U. S. P. strength. Any other is uncertain and, therefore, should not 
be relied upon. The mosquito will not settle on the skin or bite anyone 
exhaling the odor of this unpleasant substance. 

The water of artesian wells contains, as a rule, much more mineral 
matter than that from surface wells or springs; and among the mineral 
contents the sulphides generally are prominent. Memphis is supplied 
by such wells, and a number of them give water from which a strong sul- 
phurous odor is exhaled. May not the immunity of the artesian-water 
drinker have been due to the fact that the mosquito would not attack him 
by reason of his body exhalations ? 

In the experiments made in Cuba with yellow-fever infected mos- 
quitoes, it was noted that sometimes the insects would not bite certain 
persons. Why? No attempt was made, so far as I know, to answer this 
all-important question. 

Calx sulphurata, commonly denominated calcium sulphide, has been 
employed as a remedy for various infectious maladies during the last few 
years by many practicians. Given in doses of five grains a day and upwards 
saturation is produced in a few hours, as denoted by the exhalation of the 
characteristic odor upon the breath or from the skin. This saturation may 
be sustained for weeks, the medication being absolutely harmless to the 
patient, even when administered to adults in doses up to 50 grains per diem. 
If the doses are too large, nausea is caused. As a rule, it is best to give 
small doses, such as gr. 1-6 to 1-2, and repeat them every half-hour, 



68 MALARIA 

as by this means nausea is avoided and saturation secured with the 
smallest possible quantity of the drug. 

When the body is thus saturated with the sulphide, in most instances, 
no insect can be induced to bite it — mosquito, flea, fly, bedbug, redbug, and, 
chigger, midge, black-fly or any other insect-pest with which the human 
race is tormented. The writer has kept patients saturated thus for weeks, 
in treating gonorrhea, tuberculosis, diphtheria, etc., and has never known 
any harm to result. Many enthusiastic advocates of the sulphides claim that 
no known microorganism can exist alive, in the body of a person thus satu- 
rated, therefore why may we not have in this both a preventive and a cure ? 

The sulphide should not only be taken internally, as above outlined, 
but should also be applied to exposed parts of the skin; for which purpose 
the following formula may be advantageously employed — Calx sulphurata, 
U. S. P. gr. 18; glycerin, i oz.; water 2 oz.; mix. This should be applied 
freely to all exposed parts of the skin before leaving the sheltered parts 
of the house, especially after sundown, and the application should be 
repeated every one to three hours as required. 

One caution is essential — the sulphide (calx sulphurata) must be of 
good quality — full U. S. P. strength, carrying at least 60 per cent of the 
monosulphide. This drug is difficult to manage, decomposing sponta- 
neously, and unless fully up to the pharmacopceial standard should not 
be depended upon. 

The ordinary drug on the market, both in powder and tablet form, 
ranges in strength from a mere smell all the way up, the U. S. P. shelf 
being very lonesome. 

The problem of exterminating the mosquito is proving more difiicult 
than at first apprehended. It has recently been announced that the insect 
finds a breeding place in the moist dirt at the base of leaf stalks, to which it 
is obviously impossible to apply kerosene. But if we cannot exterminate 
the last of the insects, there is no reason why we should not destroy all we 
can reach, for there is assuredly less danger from a few than from millions. 
Let the swamps be oiled, then, and the tanks kept covered, and the open 
drains shut in; and each householder instructed as to the danger from 
standing water to which the insects may obtain access. The sick must be 
carefully protected from mosquitoes by screens that there may be no 
infection of insects to carry the disease further. Window and door 
screens should be added to the bed-canopies in universal use, and fumi- 
gation by burning insect powder and niter employed to destroy or drive 
out any that have obtained access to the rooms. 

Duncan found no prophylactic value in arsenic, but quinine three to 
five grains a day reduced the number of cases one-half. Corre found it 



MALARIA 69 

did not prevent pernicious forms. Celli speaks well of methylene blue as 
a prophylactic. Manson considers tea, coffee and small doses of alcohol 
of service; the last only after the day's work is done and there is no 
reason for going again into the sunlight. Crudeli praises lemon decoction. 

Three methods may be employed to break up the chill: — A hypodermic 
of pilocarpine gr. 1-6, enough to cause free sweating and thus advance the 
paroxysm to that stage. This is useful in hyperpyretic forms and many 
others, the only contraindications being extreme debility, collapse and 
pulmonary hyperemia. Next, a hypodermic of atropine gr. 1-134 to 1-67, 
to which brucine gr. 1-20 to 1-10, or strychnine gr. 1-30 to 1-20, may be 
added if the debility is extreme. This is especially indicated in the algid 
form, where intense cutaneous vasomotor spasm is to be quickly unlocked, 
and failing vitality revived. It is also to be used in hemoglobinuria, where 
strychnine has given the best results of any remedy as yet reported to us. 
Full doses are essential; and the physician who does not comprehend 
dosage for effect has no business treating pernicious#malarias. 

The third method is the use of chloroform by the stomach, which has 
been already described. The local effect of chloroform on the stomach is 
powerfully stimulating, and to this rather than its toxic action the benefit 
is probably due; though as a relaxant of spasm it acts also as atropine does. 
It is best given in either pure alcohol, or with capsicum, ginger, camphor 
or other revulsants, to get the greatest local stimulant effect. "Bring the 
tears to the eyes." Give the hottest thing at hand, undiluted. 

Reports from very many American physicians indicate the absolute 
necessity of keeping the alimentary canal clear and aseptic, the elimina- 
tion free. "To neglect the liver is simply suicide here," said an old 
physician from the Carolina rice fields. Many cling to calomel because 
they have learned to know, use and trust it; but a grain of emetine will 
clear the liver thoroughly without salivating. But so great are the advan- 
tages from emptying the bowels and giving zinc sulphocarbolate, that 
many believe this as essential as quinine. 

Excepting possibly in the severer acute attacks, it seems likely that the 
arsenate of quinine in doses of a grain a day equals ten to fifteen grains 
of the sulphate. If so, the smaller dose and freedom from objectionable 
features of big doses are worth considering. But in the dangerous fevers 
of the tropics give quinine to effect. The last case of this seen by the 
writer was in consultation with the late Prof. William H. Pancoast, in 
the person of a physician just returned from the Chagres district. The 
symptoms indicated the so-called "malarial" yellow fever — bilious 
remittent. He got quinine in doses of 20 grains. Next day his tempera- 
ture reached 105 F., and the quinine was raised to 40 grains. That 



70 MALARIA 

night the physicians were called in, as the thermometer showed 106.5 F. 
The quinine was raised to 60 grains, given by the muscles and rectum, 
and next morning he was convalescent. But such doses are not to be 
given heedlessly or needlessly. This world is full of doctors who seek 
reputation as "terrible fellows, " by giving such doses to any ordinary 
case of ague, and bragging about it afterwards. One of the writer's 
patients had been rendered permanently deaf by such a dose, adminis- 
tered in Cincinnati, by a prominent teacher of therapeutics. 

In India the practice for enlarged spleen is to rub into the skin over 
this organ a lump of ung. hydrarg. biniodidi as large as a bean, and then 
expose the naked skin to the rays of the sun or of a hot fire. In Germany 
the patient is placed in a hot bath, and a half or quarter-inch stream of 
very cold water is directed against the skin over the spleen, under the hot 
water. Hypodermics of ergotin have been vaunted. The most effective 
method is the use of the indicated remedy, berberine, which contracts 
relaxed connective tissue. Give gr. 1-6 every two hours, for a month; 
with a full daily dose of quinine arsenate, keeping the bowels clear and 
aseptic. The dose of berberine may be raised to 20 grains a day if neces- 
sary, but there is much benefit in the steady, persistent administration of 
small doses. 

The writer believes it best to give quinine in divided doses, so that 
there shall not be a moment in which the blood is not so charged with 
it as to render it impossible for the parasites to mature in safety. No 
matter how large the single dose, it will only act on those that are in an 
unprotected stage of development, and the rest will remain to propagate. 

Has the tremendous stimulation of leucocytes caused by pilocarpine 
any value in multiplying the defenders of the body? If so, how about 
nuclein? Now that study of the plasmodia has given us some certainty 
as to diagnosis, and a means of testing scientifically the progress of the 
malady and the effect of remedies, we may begin to study the therapeutics 
with some better means of judging than the recovery or death of the patient 
— an event that may be post hoc or propter hoc. 

Burggraeve called especial attention to the larval forms, in which 
the malarial attack assumed the aspect of some organic malady — gastritis, 
meningitis, apoplexy, lumboabdominal neuralgia, etc. In the cold stage 
he gave strychnine arsenate or sulphate, a granule every quarter hour, 
with hot aromatic drinks. Mustard should be applied over those parts 
on which the disease seemed to fasten itself; and general frictions used, 
the patient being warmly covered. In the hot stage, with fever of 102 
to 104 F., he gave aconitine with strychnine, a granule each every fifteen 
minutes, with warm aromatic wine. Headache he relieved by applying 



MALARIA 71 

vinegar to the forehead. In the sweating stage the bed should be changed; 

plenty of fresh air and nourishing diet secured; abundance of quiet repose; 

and during the apyrexia, with regularity and constancy he gave quinine 

arsenate, sulphate or hydroferrocyanate, and strychnine arsenate; one 

or two granules of each every quarter or half hour. The same treatment 

suited larval forms, with dry cups for pain. 

For the dysenteries of malarial localities he advised mineral acids, 

with quinine arsenate and hydroferrocyanate. Ipecac and mercury he 

considered apt to aggravate the weakness and local disease. 

In paludal anginas and diphtherias he gave calcium sulphide and 

acids, especially lemon juice, with quinine. 

Diathetic paludal gastralgias were quieted by quinine, strychnine and 

hyoscyamine, a granule each until sedation was obtained. 

Gabriel Viaud, in a suggestive paper on the malaria of cities, enumer- 
ated the disadvantages under which the citizen labors, and the inevitable 
effect on his endurance, especially the lowering of vital resistance. He 
says: "To combat this permanent infection of the organism of the inhabi- 
tant of the city, this fever palustral, this malaria endemic, we have really 
efficacious therapeutic resources. In the unhealthy provinces of Lombardy 
the living elements of the paludal fever are neutralized by the alkaline 
sulphites and by arsenic. Tommassi Crudeli has shown the good effects 
of arsenic on populations exposed to malarial effluvia, the active agent of 
paludal infection. It has often been remarked in the home of malaria, 
that after arsenical treatment the fevers recur more rarely than after treat- 
ment with quinine, and even that individuals cured by arsenic often enjoy 
a durable immunity against renewed aggressions of the malaria. Other 
Italian physicians have obtained the same results in the Roman Campagna, 
the Tuscan Maremma, and the Italian pouille. It is possible then to 
put the human organism in a state of defense against the malarial infection 
by means of medication, let it be arsenical, sulphide, or tannic. The 
essential is to impress upon the internal physiologic milieu such a modifica- 
tion that the germ of infectious disease is not cultivable there. This 
prophylactic medication is rendered very easy today for the toxined inhab- 
itant of cities, grace to two heroic remedies, embodying marvelously the 
properties of the sulphide and arsenic, so vaunted in Italy, the land of 
fevers — calx sulphurata and strychnine. All experiments made, all 
clinical facts scrupulously observed, prove that progressive impregnation, 
arsenical, sulphidal or strychninal, is the best preventive of grippal affec- 
tions, influenza, malaria and all general urban infections. When one 
is under obligation to live with his pathologic enemies in cities, to sojourn 
in human marshes, in the midst of all the infections engendered by the 



72 DYSENTERY 

agglomerations and the excreta of social life, what is more indicated than 
to prefortify against fevers and possible complications by internal steriliza- 
tion of the tissues? What more rational than to place oneself under the 
palladium of strychnine and calcium sulphide?" 

DYSENTERY 

Dysentery prevails sporadically in all parts of the globe, in the tropics 
extensively, occurring as an epidemic in temperate regions. It is still a 
common camp disease, and was frequent in institutions, but has become 
less so. It becomes more frequent and severe as we approach the equator. 
Its habitat is similar to that of malaria, prevailing in low, wet places, and 
mostly at the close of the summer. Drainage dissipates both. Both may 
occur in the same person at the same time, and each predisposes to 
the other. 

But this resemblance is superficial; each prevails without the other 
and the specific cause is totally different. Shiga discovered a bacillus in 
the dysentery of Japan to which he attributed that disease, and this has 
been detected in the same malady in the Philippines, Porto Rico, Germany, 
England, and in cases of cholera infantum in this country. Whether this 
is the only organism capable of inducing inflammation of the mucous 
membrane of the large bowel is another question. 

The bacillus dysenteriae is as long as that of typhoid fever, growing 
on all culture media, gelatin colonies assuming the shape of a grape leaf. 
It does not liquefy gelatin, ferment sugar or coagulate milk. It is at first 
slightly motile. Fed to animals, it has no effect unless the mucosa is 
already irritated. 

Dysentery caused by this organism may occur sporadically or in 
epidemics. In the Philippines it appears about the end of the rainy season. 
The infection is believed to enter with the drinking water. The incuba- 
tion is within forty-eight hours. The onset is abrupt, with fever, abdomi- 
nal pains and frequent calls to stool, the first discharges being fecal, then 
intestinal mucus, and then blood, pure or mixed with the preceding. 
The stools are small and straining becomes incessant. The pulse is fast 
and tends to become small, as the fever rises to 104 F.; the tongue is 
coated and dry; the thirst tormenting; as the body is drained of fluids 
it shrinks, and the face becomes small and pinched. Grinding pains in 
the abdomen add to the distress, which becomes acute; delirium sets in, the 
prostration becomes extreme, and the patient may die in two or three days. 

In less severe cases the symptoms are not so acute, and begin to sub- 
side in a few days, the tenesmus and tormina lessen, the temperature 
falls, and recovery ensues within two or three weeks. 



DYSENTERY 73 

Subacute and chronic forms prevail, when the case drags along for 
months, the patient becoming excessively thin and weak, with several 
stools a day, mostly in the morning. 

In the acute form the mucous membrane of the colon is swollen, very 
red, with raised folds. Ecchymoses are found, and much or little of the 
surface of the mucosa may be neurotic. All the coats may be infiltrated, 
gray to black, necrotic or even gangrenous. The ileum may also be 
hyperemic. In subacute cases there is less swelling and the solitary fol- 
licles project. The mucosa is less deeply involved. 

Many writers now describe amoebic dysentery as a distinct form, 
dependent on the amoeba dysenteriae. This is found in the mucus, any 
little flake presenting it in abundance. It is about 20 micromillimeters in 
diameter, with a clear outer zone or ectosarc and a granular inner zone 
or endosarc, a nucleus and vacuoles. The movements are those of any 
amoeba. They may contain red blood cells. The slide should be warmed 
in cold weather. Manson denies this as a specific cause of dysentery, 
though he acknowledges that it is frequently found in the stools and the 
tissues, as w T ell as in the pus from hepatic abscesses. But he has repeatedly 
failed to find the amoeba in typical cases, and an amoeba indistinguishable 
from it is found in the stools of healthy persons; while Gasser could trace 
no relation between the number of amoebae present and the severity of the 
attack. Amoebae of many kinds abound in countries subject to dysentery, 
and at least six other varieties have been found in dysenteric stools. Mean- 
while this malady has been confidently attributed to various organisms, 
such as bacillus coli commune, streptococci, bacillus pyocyaneus, Dur- 
ham's micrococcus, etc. It seems likely that it will eventually be acknowl- 
edged that no one organism possesses a monopoly of the power of exciting 
inflammation of the large bowel, as has been shown to be the case with 
the lungs. 

Amoebic dysentery is thus described by Osier: The onset may be 
acute, with the symptoms already described, the fever not high; 4 some- 
times large sloughs pass; emaciation is rapid and death may occur within 
a week. There may be hemorrhages, or perforation and peritonitis; 
recovery in most cases, or the disease may become chronic. Extensive 
ulceration may cause chronic diarrhea, the case ending by exhaustion in 
three months. Equal emaciation is seen only in cancer of the esophagus 
and in nervous anorexia. Corneal ulcer may occur. Or, the attack may 
be subacute, becoming chronic, with alternating constipation and diarrhea; 
the latter attended with fever, pain, straining and mucosanguinolent 
stools. In the temperate zones the extreme emaciation described is not 
common; the appetite is capricious, digestion unsettled, and slight errors 



74 DYSENTERY 

of diet are followed by diarrhea. The tongue may be red, glazed and 
beefy. 

The most common form of dysentery seen in the northern United 
States is the catarrhal. This may begin as a diarrhea, the stools becoming 
less in bulk and more frequent, with griping and straining. The stools 
contain about a tablespoonful of mucus, with specks or streaks of blood. 
The desire to evacuate the bowel becomes incessant, the feeling being as 
if a lump were there to be strained out — the inflamed bowel. There is 
less fever than with an equal extent of inflammation elsewhere, but the 
suffering may be extreme. 

In other cases the onset is abrupt and the symptoms supervene rapidly, 
the severest type being manifest in a few hours. Still there is little fever, 
though the patient remains constantly on the commode. The tenesmus 
extends to the bladder. Thirst is great. By the end of the week the 
symptoms have subsided and we have recovery or the chronic stage of 
the disease. 

If the mucous membrane breaks down and loses its vitality we have 
the severe symptoms persisting, the stools become offensive from the 
presence of sloughs, and the loss of substance entails a tedious recovery 
while the gaps are filled up — if they do so at all, and do not sink into a 
chronic ulcerous state. Chronic dysentery may last for years or the 
healing ulcers may leave cicatricial obstruction of the lumen of the bowel. 
Prolonged disability results at any rate. 

The worst form of acute dysentery is the fulgurant or gangrenous. The 
stools resemble the washings of beef, depositing a coffee-ground material, 
exceedingly offensive. Dark sloughs are passed, with rings or tubes of 
membrane. Collapse supervenes rapidly, with cold extremities, algid 
face, small thready or imperceptible pulse, cold sweat, husky or inaudible 
voice, hiccough, low delirium, and generally death. 

Hemorrhage is an accident, from the erosion of an artery in the separa- 
tion of a slough. Intussusception is another accident, sometimes occurring 
in children. There is a sudden increase in the pain and straining, absence 
of fecal matter from the stools, vomiting, and a tumor to be found by 
rectal examination. 

Some abdominal tenderness is common, and the colon may be felt to be 
thickened. The liver is enlarged and tender, hepatitis may alternate 
with dysentery — often ending in abscess. Multiple abscesses are always 
fatal. 

The mortality from dysentery depends upon the nature of the epidemic, 
the condition of the patient and his care and surroundings. With bad 
hygienic elements and bad treatment it may become terribly destructive 



DYSENTERY 75 

of life. But even in India the mortality among Europeans is given as but 22 
per cent as a maximum, while in Japan it is 7 per cent and in Egypt 40 per cent. 

The sequels are more dangerous than the disease. Chronic ulcers with 
cicatricial obstruction, general atrophy of the intestinal, glandular and 
absorbent systems, wasting, asthenia, failure of digestion and assimilation, 
too often continue through the patient's remaining life. Hepatic abscess 
may occur during or months after the dysenteric attack. Here it usually 
comes on insidiously. Malaria is a not infrequent complication. During 
the Civil War typhoid often coexisted. Rheumatoid arthrites are occas- 
sionally present, probably septic or autotoxemic. Serous inflammations, 
pyemia, pylephlebitis, chronic nephritis, non-renal edema, paralysis and 
digestive failure, are more or less frequent sequels. 

The diagnosis is easy — the frequent, small, mucous and bloody stools, 
tormina and tenesmus, slight fever and severe suffering, suffice. Rectal 
ulceration, syphilis and cancer cause straining and bloody stools, but their 
onset is gradual and their history different. The gangrenous or diph- 
theritic form has been mistaken for typhoid fever, but blood does not appear 
in the stools of the latter until later, there is a swelling of the spleen, the 
rose rash, and the Widal reaction. The amoeba can easily be detected in 
stools of that form, which is also distinguished by its irregular course and 
tendency to chronicity, the ambulant habit of the patient and tendency to 
hepatic abscess. Leucocytosis is to be expected only during complications. 
"In the acute specific form the blood-serum agglutinates the Shiga 
bacillus" (Osier). 

Prophylaxis: — The position of those who insist on the dissemination 
of the germs of dysentery by water is markedly strengthened by the diminu- 
tion in the number of cases developing when the use of pure drinking water 
is made compulsory. Persons residing in infected districts should drink 
no water unboiled, or without the addition of potassium permanganate. 
Infection by dust, flies, utensils and food, should be avoided. Fruit that 
is unsound, and other food that might excite diarrhea, may not give rise 
to dysentery but at least they, open the door to it. The presence of the 
amoeba in the stools of healthy individuals does not so much disprove its 
etiologic importance, as it shows that a suitable soil is also essential. In 
tropical lands the woolen abdominal bandage is highly prized by intelligent 
residents. Persons reduced by pre-existent disease, by privation, scurvy, 
malaria, alcoholic and other excess and dissipation, or weighed down by 
grief or anxiety, are more likely to have this disease and to have it in worse 
forms, than persons in good mental and physical health. No age, sex or 
occupation is exempt; nor is any race in itself and apart from its habits 
immune. 



76 DYSENTERY 

Trestment: — What are the objects of treatment ? First and emphatically 
not to stop the discharges. This idea has cost many lives. The writer 
has seen men die of dysentery, their bowels locked up by opiates and the 
pupils tightly contracted. Evidently it was not the frequency or size of the 
intestinal discharges that killed them. The first object of treatment is to 
moderate the violence of the inflammation so as to preserve the life of the 
affected tissues; next to sustain the vital powers until the storm is past, and 
third to prevent autotoxemia. 

Empty the inflamed bowel, cleanse it, make and keep it aseptic, 
deplete the swollen tissues and cool their virulent heat. 

Begin with calomel gr. 1-6 every half hour for six doses; follow with 
small doses of a saline laxative repeated every two hours. This will remove 
all fecal matters — which assuredly are not good for an inflamed bowel — and 
deplete the swollen tissues without irritating them. Frequently constipation 
exists in the upper bowel while dysentery rages below it. The saline should 
be given several times a day, in doses too small to irritate, throughout the 
attack. Keep the upper bowel aseptic by zinc sulphocarbolate gr. 2 1-2 
every two to four hours also — it is not good to allow a diseased tract to 
become poisoned by toxic decomposition products, nor to allow the blood 
to become deteriorated by toxin-absorption from the alimentary tract. 

The inflamed colon and rectum are within the reach of local remedies . 
Irrigate the colon with physiologic salt solution, as hot as can be borne — 
and this is hotter than the nurse 's hand will bear in many cases — and there 
will be a notable diminution of the tenesmus and the inflamed tissues will 
be soothed and depleted. This may be repeated as often as the patient 
desires — he will know when the irritation has returned. If the malady 
hangs on, a grain of silver nitrate in each half pint of hot water will be useful. 
Even in the height of the inflammation this has a most gratefully soothing 
effect, and many prefer it to salt water. These injections are best given 
with the patient lying on the back with the hips raised. The tube should 
be well lubricated and introduced with the utmost gentleness, allowing a 
little water to flow in when the point is caught. If there is much involve- 
ment of the rectum it will be best not to try to introduce the colon tube but 
to make frequent half -pint rectal injections with the silver, until the irritation 
there has subsided. 

Keep the patient at rest, in bed. Insist on the use of a bedpan, and 
forbid straining. Tell the patient it is the inflamed bowel that feels so like 
a foreign body, and that it cannot be strained out but that this will make 
the inflammation worse, and he will obey better than if no explanation is 
vouchsafed him. The food should consist of articles wholly digested in 
the stomach, and affording as little waste as possible. The raw white of 



DYSENTERY 77 

egg, beef and oysters, the beef powders predigested, bovinine, and juices 
freshly pressed from sound ripe fruits, are best. Hot milk and cafe au lait 
are excellent. Later, any clear nutritious soup may be added, but starches 
should be withheld till convalescence is well established. Plenty of pure 
water should be given. Alcohol is always injurious, even in those accus- 
tomed to its daily drinking. 

Ipecacuanha was first introduced as a marvelous remedy for dysentery. 
It has been used with success and repeatedly allowed to fall into desuetude, 
but still stands at the head of remedies for the severer forms of this malady. 
Especially in India it has been widely employed. It soon became evident 
that the virtues of this remedy did not depend on its emetic properties but 
were developed best when emesis did not occur. Efforts were made to 
secure the specific effects by excluding the emetine, but with unsatisfactory 
results. It was not then known that ipecacuanha contained two alkaloids, 
the acrid emetic cephaeline, and the milder cholagogue emetine on which 
the specific virtues of the plant in dysentery depend. There is little emetic 
tendency about emetine unless it is given dissolved in a large quantity of 
warm water. To avoid nausea let the emetine be taken in tablets, swal- 
lowed whole, without chewing, or liquid, and have the patient lie absolutely 
quiet for fifteen minutes or longer after each dose. By this time the dose 
will be dissolved, absorbed as quickly as dissolved, and no nausea will 
result. If the stomach is unusually irritable inject morphine gr. 1-8 over 
the epigastrium just before giving the emetine. 

The average dose is one grain of emetine, and this may be repeated in 
two, four or eight hours, according to the gravity of the case. In many 
cases the patient will fall asleep within fifteen minutes of taking this dose, 
sleep eight hours, and on awaking pass two spinach-colored stools, and be 
convalescent. Smaller doses then suffice. The writer has employed this 
method in all forms of dysentery, in the tropics and the temperate regions, 
and has found no other treatment as effective. 

How does emetine act? We do not know, but believe the effect will 
prove to be associated with its cholagogue action. Many physicians have 
advocated mercury in various forms, principally corrosive sublimate, 
following Ringer, giving about gr. 1-134 every hour or two. This may 
have some antiseptic effect, or it also may act in stimulating the secretions 
of the digestive system, as emetine does. Veratrine has also been advised, 
in very small doses, gr. 1-500 to 1-134 every two hours. It performs its 
certain functions of relaxing tension, equalizing circulation, and opening 
the doors for elimination universally. Given judiciously in the doses 
mentioned it will not increase the irritation but allay it. The specific 
indication for veratrine is probably defective renal excretion. In ordinary 



78 DYSENTERY 

dysenteries there is not usually enough fever to render it a leading indication, 
but the hyperemia of the affected tract requires relief as elsewhere; and this 
is best accomplished by the local treatment, and emetine. 

The writer has employed bismuth very largely, in all forms, and finds 
it useful as a topical application to allay inflammation. It is best given in 
suspension by enema, in full doses — one to four drams in half a pint of 
mucilage. But it is doubtful if it offers much advantage over hot water 
used judiciously. 

Osier commends in the amoebic form warm enemas of quinine solution, 
i to 5,000 or 1,000. He has seen no bad effects from large enemas. Hot 
applications to the abdomen are grateful, the clumsy and heavy poultice 
being well replaced by a Japanese muff-warmer wrapped in flannel. 

In the malignant form, where the symptoms in a very short time develop 
the utmost intensity, it is necessary to arouse the vital forces with the 
speediest and most powerful of stimulants. In the sudden attacks common 
in the tropics, taking the form of dysentery, cholera morbus or pernicious 
chills, there is in India a proverb that if the tears can be brought to the 
patient's eyes he may be saved. For this purpose mixtures are made 
resembling the following: Chloroform, sp. camphor, oil of cajeput, tr. 
capiscum, of each two drams; ether an ounce. Of this a teaspoonful is 
given, undiluted, and repeated in ten to thirty minutes if necessary. It is 
quite effective, arid by it many an attack of this kind has been broken up in 
a few hours. As time is precious in such cases an extemporaneous mixture 
can be made with the remedies at hand; — ginger, red pepper, camphor, 
"pain killer," Hoffman's anodyne, sweet spirits of nitre, or the contents 
of the family spice-box. The one essential is that it be hot enough to 
" bring the tears to the eyes," and given promptly, before the damage has 
been done. 

Manson advises calomel when the ipecacuanha and saline treatment 
has failed and bloody mucous stools persist; giving a grain with ipecacuanha 
and opium every six hours. In Germany also this remedy is favored for 
membranous cases. But the writer does not see why there should be need 
of such treatment if emetine and enemas are intelligently employed. It is 
a poor sort of a doctor who is ever "trying" remedies. As one becomes 
accustomed to positive medication with therapeutic certainties, he gets 
out of this vicious method of tentative medication, timorously administering 
drugs without any real knowledge what result to expect, but simply a vague 
hope that the patient may be better after taking them. 

Manson says that simaruba — Ailanthus glandulosa — has succeeded 
when other remedies have failed; but it must be given in much larger 
than pharmacopoeial doses. Half an ounce is advised every second morning 



DYSENTERY 79 

for four doses. Maberly advocates a South African plant, Monsonia ovata, 
as giving wonderful results. Cinnamon, pomegranate, mangosteen peel, 
and other drugs have been used with advantage. As regards cinnamon, 
it has useful properties not often suspected by those who look on it 
as merely a carminative. The writer has used it with great benefit in 
menorrhagia, giving two drams of the spirit at a dose. In chronic cases 
of dysentery it may be likewise effective in large doses. 

In chronic cases Manson advises a course of ipecacuanha, followed by 
silver nitrate locally. Clear out the bowel by ipecacuanha, salines, calomel, 
castor oil, rest and diet for a week at least; then give a minute dose of castor 
oil and a large enema of warm water, with two or three teaspoonfuls of 
sodium carbonate to two quarts of water; when this has passed leaving the 
bowel quite empty, throw in two to three pints of silver nitrate solution, 
half to one grain to the ounce of distilled water; using a fountain syringe 
and colon tube, the patient lying on the back with hips raised. The injec- 
tion should be retained as long as possible, and repeated every few days. 
Osier says that no case of argyria has been known to result from these silver 
injections. If improvement does not follow immediately, or if the irritation 
is increased, the injections must be stopped. 

Chronic dysentery may be cured by the strict stomach diet, silver locally, 
and intestinal antiseptics, rigidly persevered in for three months. The 
writer does not personally know of cures resulting from any other method. 

After an attack has subsided constipation is frequently annoying. The 
morning dose of saline laxative, with careful diet, and an occasional flush- 
ing of the colon with mild antiseptic solution, will answer every useful 
purpose. But the enema habit is to be avoided, and the saline reduced 
daily as the habit of regular evacuations is restored. 

The value of the abdominal binder is acknowledged by those who use 
it properly; others are skeptical. It should be of all-wool flannel, and 
made to cover the abdomen from ribs to brim of pelvis, held smoothly by 
crinoline or other stiffening; and worn through the day only in all seasons. 

The writer firmly believes that the best way to prevent hepatic abscess 
is to keep the alimentary canal as nearly aseptic as is possible. 

Balard D 'Heronville details the case of a man of 24 years, a gardener, 
recently arrived from military service in Algiers. He had had an attack of 
violent dysentery for two days. Three days' constipation preceded the 
outbreak of dysentery. This, with general malaise, headache and obstinate 
saburral dyspepsia, frequently precede dysenteric attacks in hot countries. 
The abdominal symptoms were violent colics, frequent evacuations of 
stools, serous, greenish, slightly sanguinolent, with glairy lumps mixed with 
scrapings from the bowel, and tenesmus after each stool. With this a pro- 



80 CHOLERA 

nounced anemia, the transparent skin beaded with profuse sweats, temp. 
36. 8 C, completed the picture. 

He prescribed rice water and rhatany, woolens and opiate poultices 
over the hypogastrium. Absolute diet. Next morning the patient reported 
a little more sleep, temp. 37 C, stools as frequent, tenesmus more painful, 
feces not improved in appearance. The prostration persisted. Prescribed 
bismuth and opium, with three lukewarm general baths during the day. 
"That evening the father sent for me in great haste; his son showed great 
weakness; he 'flanked' (flunked?) I could not hesitate to admit that 
in view of the infectious malady the medication and hygiene were incom- 
petent to cope with the trouble. The temperature was 36.4 C, the stools 
more strongly sanguinolent and more and more frequent. I thought of 
ipecac in large doses, and of glycerin a dessertspoonful every hour, employed 
with success in China where dysentery is common among the European 
colonists; but it was night, and I postponed till morning these remedies. 
But I sent the patient a vial of calcium sulphide granules, with directions 
to take one every half hour, continuing the former prescriptions. 

"At the earliest hour I was at the bedside of my patient, whom I found 
to my surprise in a better state. He had taken twelve of the granules, 
then slept. Only two stools since last night's visit; temp. 37.3 C. I 
confined myself to the sulphide, a granule every hour; directing the atten- 
dants to watch the effects, continuing the bismuth and baths. Three days 
later he arose and began a brief convalescence. Quinine and strychnine 
quickly removed the debility. When the patient came to pay his bill, he 
said: 'M. le Docteur, do you see, it was those graunles that cured me; 
without which I would have passed over to the left.' And that is 
how your servant became a dosimetrist, and a convinced partisan of 
calcium sulphide. " 

CHOLERA 

The wings of cholera have been clipped by the health officer. Since 
1873 there has been no prevalence of the malady in America, and no serious 
epidemic has prevailed in the last fifty years. In 1893 a few cases were 
imported but the disease failed to gain a foothold. 

The specific cause of Asiatic cholera was discovered by Koch in 1884, 
in the comma bacillus. It is a bent rod, thicker and shorter than the 
tubercle bacillus, sometimes occurring in a spiral shape. It is a spiro- 
chete. It has been found in the water tanks of India, and in the water 
of the Elbe during the Hamburg epidemic in 1892. It may be found in the 
intestines of persons suffering with cholera, in the earliest stools, and 
very plentifully in the rice-water dejecta, and rarely in the vomit. Even in 



CHOLERA Si 

the stools of persons not choleraic they are present during a general epidemic. 
In the most rapidly fatal cases they have not time to penetrate the intestinal 
walls and glands. To produce this disease in guinea pigs it is necessary 
to neutralize the contents of the stomach and to paralyze peristalsis with 
opium. 

The symptoms are due not to penetration of the blood or tissues by the 
bacillus but to absorption of its toxin from the alimentary canal. As long 
as the intestinal epithelium is intact no absorption takes place. 

The blood serum of men or of animals who have recovered from cholera 
contains a substance that causes rapid destruction of the comma bacilli. 
It is not an antitoxin. Haffkine has employed this serum as an 
immunizing agent in India with success. 

Certain conditions are necessary to render the comma bacillus when 
swallowed infective. Contagion is slight; attendants are rarely affected. 
Laundresses and those who come in contact with the stools are especially 
liable to contract cholera. The custom of watering growing vegetables 
with diluted sewage is responsible for many cases, especially such plants as 
are eaten raw. Milk takes up the infection. On bread, meat and butter 
the bacilli live for a week. In flies they survive at least three days, and 
these insects are probably a frequent source of food infection. Dry bacilli 
die in a very short time. Water is the chief medium of infection, as used 
for drinking, preparing food or washing. Infection of the water-supply 
causes the great epidemics. Then there is a sudden explosion of the 
disease, numerous persons being attacked simultaneously. In other cases 
the malady spreads from individuals, and cannot always be traced. This 
water-contamination theory meets with some dissent, and observers in 
India found comma bacilli in water-tanks after the epidemic had ceased, 
as plentifully as during its prevalence. 

Cholera has always followed the lines of travel. Formerly it spread 
at the ordinary rate of a man's progress, and this fact has been woven into 
the legend of the Wandering Jew. But since steam has given wings to man 
the cholera bacillus has also availed itself of more rapid means of progres- 
sion. The seacoast and low lands are more affected than high altitudes, 
possibly because more exposed and the population greater. The disease 
is more prevalent during or near the close of the hot season. All ages 
are liable, the intemperate and feeble more so; fear has an influence in 
predisposing, also grief and kindred depressing emotions. Any disturbance 
of digestion, weakening resistance or injuring the intestinal epithelium, 
probably opens the door to cholera. 

"There are no anatomic characteristics." Comma bacilli may be 
found in abundance in the bowels after death. High temperature may 



82 CHOLERA 

follow death. Rigor mortis sets in quickly and may cause muscular move- 
ments. The body is drained of water, the blood thick and dark, tissues 
shrunken, peritoneum sticky, intestine congested, thin and shrunken, 
containing a fluid like the stools. The mucosa is swollen, hyperemic in 
acute cases, congested most in Peyer's patches, denuded of epithelium. 
The spleen is small, the liver and kidneys show cloudy swelling, the renal 
epithelium is eroded, heart flabby, right side engorged, left empty, lungs 
collapsed and congested at the base. When death is postponed until 
reaction there are evidences of intestinal inflammation. At first the stools 
contain only the comma bacilli; later other organisms accompany them. 
Incubation lasts three to five days. The first stage begins with diarrhea, 
painless, sometimes so slight that the patient is simply conscious of an 
easier stool than usual. Or, there may be nausea, colicky pains, headache, 
depression of strength and of spirits. This may continue a few hours or 
days. During an epidemic all diarrheas are to be considered choleraic and 
measures taken accordingly. With the general diffusion of the cause an 
outbreak simply depends on the concurrence of favorable conditions, and 
an ordinary diarrhea will supply these. Some leucocytosis is present, the 
large mononuclear cells being abundant. 

After this preliminary stage or without it, the symptoms of cholera 
asphyxia may set in suddenly. The diarrhea becomes profuse, the stools 
at first fecal but soon assuming the characteristic " rice-water" appearance. 
Cramps and tenesmus occur with incessant purging. Prostration is rapid, 
the patient shrinking in a few hours to a shadow of his former rotundity, 
and collapse supervening with ashen features, cold skin covered with clammy 
sweat, eyes sunken, nose, fingers and toes blue, cheeks hollow, voice a 
husky whisper, pulse threadlike or imperceptible, axillary temperature 
subnormal, rectal perhaps elevated. Consciousness is undisturbed but 
lethargy comes on, deepening into coma. Cramps occur in the muscles 
of the calves as the blood becomes thick from the deprivation of water. 
The rice-water stools contain flakes of epithelium and mucus, sometimes 
blood; they are all alkaline and devoid of odor. The saliva ceases, urine is 
concentrated and scanty, sweat abundant, and in nursing women the milk 
may be increased. Death may follow the outbreak in two hourSj or 
within a day. Sometimes the toxin is so concentrated that the patient dies 
quickly without any diarrhea. These cases are known as cholera sicca. 
The urine contains albumin and granular casts. 

Should the patient survive this onslaught the stage of reaction sets in, 
termed cholera typhoid. In this we see the results of the disease. Warmth 
and color return to the skin, perhaps with a rash; the pulse becomes full and 
stronger, the kidneys secrete, diarrhea and vomiting subside, cramps cease 



CHOLERA 83 

and temperature rises above normal. This may soon pass into conval- 
escence, but if the attack has been a serious one the effect is soon manifested 
in a dangerous enterocolitis. The patient becomes very weak, the pulse 
feeble and fast, tongue dry, and delirium sets in, usually of the low, mutter- 
ing typhoid type. The stools become fetid and may contain blood. The 
urine may be suppressed, the tubuli uriniferi blocked by detritus, acute 
nephritis or uremia developing. Stupor supervenes and ends in fatal coma. 

All grades of severity are met in an epidemic, from those that do not 
go beyond diarrhea — termed cholerine — to the dry choleras. 

Among the sequels diphtheritic affections of the bowels, throat and geni- 
tals are not rare. Nephritis, pleurisy, pneumonia, abscesses, suppuration 
of the parotid and local gangrene have been observed. Cramps in the 
extremities sometimes persist for some time. 

When Asiatic cholera is epidemic it can only be diagnosed from cholera 
morbus by the bacteriologist. The symptoms differ only in degree. 
Arsenic, corrosive sublimate, corrosive zinc salts, muscarine and the 
poisonous amanitas cause symptoms closely resembling cholera. 

The mortality varies between 30 and 90 per cent. It is greatest in the 
beginning of the epidemic; and in persons debilitated by intemperance or 
preexisting disease. The aged die. A sudden and violent onset is fatal; 
cholera sicca hopeless. 

When an epidemic of cholera is threatened preparations should be 
made by cleaning up the ports and cities where it is most likely to enter. 

As infection is given off only through the stools, and taken in only by 
the mouth, the rules of personal hygiene are obvious. Stools should be 
thoroughly destroyed, and as acids are deadly to the comma bacillus, 
an ounce of any of the strong mineral acids in the vessel will accomplish 
this, if left to stand an hour after each stool is passed. Linen that has 
been worn by the patient should be well soaked in any acid that will not 
injure its texture, such as crude pyroligneous acid; or it may be burned 
if the acid is not at hand. The nurse must rinse in acid solutions her 
hands, the dishes, and everything used in the sickroom, before allowing 
them to be taken from the room. 

Unneeded persons should be sent out of the dangerous region — the 
fewer the individuals who are food for the epidemic the less extensive 
it will be. This does not apply to those who already have the infection, 
for they would spread it wherever they go. Such persons should be sent 
to a detention camp, and retained there under observation until they are 
surely free from danger. Those who must remain in a city stricken with 
cholera should refrain from taking into their mouths any food or drink 
that is not cooked or boiled, or acidulated. Fruit eaten from the stands 



84 CHOLERA 

and well powdered with street dirt may be infected; no one can tell when 
or how the drinking water may be polluted; and as only those who take 
risks contract the disease, it is easy to keep out of its clutches by not taking 
risks. Even the simple precaution of adding lemon juice to the drinking 
water will suffice, as all acids are fatal to the comma bacillus. 

Treatment: — The slightest sign of diarrhea calls for immediate treat- 
ment; and this malady differs from other diarrheal affections in that it 
is absolutely necessary to lock up the bowels at once. The advice of Sir 
George Johnston, to begin with castor oil, reappears in the newspapers 
every time cholera comes into prominence. It sounds like common sense, 
to sweep out of the bowels the offending matter; and the unquestioned 
utility of this method in ordinary diarrhea adds to the force of the advice. 
But Asiatic cholera is not an ordinary diarrhea; and in India, where the 
suggestion was fully tried, it proved so deadly that it was given up. This 
is one of the very few things in medical practice that is definitely settled. 

Lock up the bowels, then, with a full dose of morphine, hypodermically. 
There are many mixtures on the market that are useful, because they 
depend on morphine for their main effect — compounds of camphor, capsi- 
cum, chloroform, etc. It is best to give exactly what is needed and not 
to obscure the lesson by enveloping the remedy in a mess of others. Give 
enough to keep the bowels closed, and repeat so as to keep them so till 
the danger is passed. Feed with fluid foods that will be digested in the 
stomach and leave the bowels at rest — raw egg white, beef and oysters, 
grated hard boiled yolk of egg, fresh hot milk, and coffee, with the pre- 
digested foods, sanguiferrin and bovinine. Meat powders like somatose 
should be extremely useful here. Give small quantities every two hours. 

If the symptoms of the second stage develop, with collapse and rice- 
water stools, the remedy is atropine in full dose, hypodermically. Give 
gr. 1-67, and repeat in an hour if the blood has not returned to the skin; 
then often enough to keep it there. It directly antagonizes the symptoms 
of the disease through their whole extent, by sedating the excited vagus. 

Harkin, of Belfast, who introduced this treatment, had remarkable 
success with it in India, where he went to put his idea to a practical test. 
Atropine is the best remedy for the vomiting as well. Efforts should 
be made to combat collapse and restore warmth to the skin by hot baths 
with mustard, and hot enemas of decinormal salt solution, which by 
being absorbed restore the fluidity of the blood and thus relieve the mus- 
cular cramps. Irrigation of the bowel with weak acid solutions is useful ; 
a dram of tannic acid to the quart of water. Glonoin and strychnine 
may be given, and capsicin, and camphor, to combat depression and 
arouse the vital forces. Decinormal salt solution may be thrown under 



CHOLERA 85 

the skin, or into the veins, with great advantage. If the patient can be 
kept alive a few hours he may recover; and restoration of the fluidity of 
the blood, and excretion of urine, are thus favored. The earlier 
experiments in this line failed because they were not repeated and 
persisted with. 

In the stage of typhoid we have to deal with an enterocolitis. Mor- 
phine is here a dangerous and doubtful remedy. Irrigation of the colon 
with warm water is soothing and promotes elimination and healing. Salt 
solution is perhaps better than plain water. Hot applications to the 
abdomen are also useful. The diet should still be limited to stomach 
food. The heart may need sustaining, by hypodermics of strychnine 
and cocaine. Small doses of atropine may be needed to restrain gastric 
or intestinal irritation. But the whole treatment of this stage may be 
summed up in the word, Rest. With this, sustain the strength and enjoin 
patience. Massage will aid in removing from the muscles debris which 
may keep up cramps. Not until the intestinal epithelium has had time 
for regeneration should the patient be permitted to resume general food 
or to leave his bed. If convalescence is unduly protracted the fruit juices 
should be added to the diet, to prevent that scurvied condition so familiar 
in the convalescents from typhoid under the old rigid diet. 

CD. Ussher, of Van, Turkey, says that cholera has lost its terrors for 
him since he began to treat it with colonic flushes of quinine solution, 
and atropine employed as above suggested. His opportunities for testing 
rernedies for this malady are unusual. 

In cholera morbus Burggraeve cleared the bowels with saline laxatives, 
then under strychnine, morphine and hyoscyamine, the trouble soon 
subsided. 

In true Asiatic cholera he urged the importance of prophylaxis by 
a hygienic mode of life; taking internally a granule of strychnine and 
three of quinine hydroferrocyanate every hour; daily cleansing by saline 
laxative, adding hyoscyamine for any tendency to colicodynia. In asphyxia 
every means must be employed to promote reaction, giving strychnine 
arsenate, one granule, and quinine arsenate, two granules, every ten min- 
utes. When heat returns to the skin it should be encouraged by strych- 
nine, aconitine and digitalin, two or three granules each, every ten minutes, 
to reestablish innervation, circulation and diuresis. Add tea, with rum. 
Continue till sweating occurs; then change the patient to another room 
and bed, with an open fire. Give a strengthening diet, soups and wine, 
in small and frequent doses; lessen the bedding as the sweating dimin- 
ishes; and for at least two weeks continue the arsenates of strychnine and 
quinine. 



86 YELLOW FEVER 



YELLOW FEVER 

Yellow fever is a disease of tropical America and Africa. Its habita- 
tion is the West Indies and the coasts of the Gulf of Mexico and the Carib- 
bean Sea. In Cuba, for four centuries the principal focus of the disease, 
it has been extinguished since the American occupation. Measures are 
being taken to accomplish the same task in Vera Cruz; and it is a reason- 
able expectation that this fever will be eradicated from the Western hemi- 
sphere within a few years. Its limits in Africa are yet to be established. 

It has been a disease of the seacoast, rarely ascending beyond tide- 
water or above 1,000 feet above the sea-level; it has prevailed especially 
in cities where sanitary conditions favored epidemics; and its season has 
been, like typhoid, the close of the heated term. Frost puts an end to 
the epidemics, and to the patients. 

Investigations made by Finley, Reed and others in Cuba, have satis- 
factorily proved that yellow fever is transmitted from man to man only 
through the medium of a mosquito, the stegomyia. Experiments carried 
out under the observation of physicians who doubted this, showed that 
persons just arriving from northern countries like Norway, and especially 
liable to this disease, sleeping in clothes taken from dead yellow fever 
patients and soiled with black vomit and dejecta, did not contract the 
infection if mosquitoes were excluded. Contagion has always been 
denied; the fomites theory has been finally disproved. If there is any 
other mode by which the infection can be transmitted it has yet to be 
shown; and every suggestion yet made in that direction has been dis- 
proved. For an epidemic to arise in any city now free from yellow fever 
it is necessary that a patient suffering with that disease shall be brought 
to it, that stegomyia shall have access to the patient and bite him, and 
after an interval of twelve days obtain access to and bite other non-immune 
persons. If the original patient imported is protected from mosquitoes 
there is no danger to nurses or to the town. Persons who stay at night 
within the protection of mosquito nets are safe even if the malady rages 
in their neighborhood. 

This explains the accurate observations of the older physicians, who 
noted that those who lived on the heights around Rio de Janeiro were 
safe unless they ventured down into the city after night, when the stegomyia 
is most active; and that ships anchoring at least half a mile from the 
shore were safe — the mosquito does not travel so far in pursuit of her 
victims. Frost stops the epidemic and the mosquitoes at the same time. 
Both prevail in the autumn. 



YELLOW FEVER 87 

Yellow fever may be produced by inoculating persons, not immune, 
with the blood of infected patients. The incubation then extends over 
a period varying from forty-one hours to five days and seventeen hours. 
Guiteras thinks the disease is continued through light, unrecognized 
cases occurring in the children of the lower classes, the mixed breeds. 

Immunity does not endure for life; though if the patient has once had 
the disease a second attack is exceedingly unlikely if he remains in the 
tropics. But if he removes to a non-tropical country and remains some 
years he loses his acclimatization, and is liable to another attack. This 
is an old observation, not yet tested under the mosquito infection theory. 
When we know more of the mosquito and of the life history of the germ 
that causes the fever we may be able to explain these things better. 

But as yet the germ, which undoubtedly exists, has not been 
definitely recognized. 

AnBtomy: — There are no specific internal lesions that have been 
established. The skin is yellow; ecchymoses in the skin, free hemo- 
globin in the blood; heart sometimes fatty; stomach hyperemic, con- 
taining the black vomit, which consists mainly of blood pigment; swelling 
of glands, especially the cervical, axillary and mesenteric; liver pale or 
brownish yellow, its cells fatty; the kidneys show diffuse nephritis, the 
epithelium of the convoluted tubes is swollen and granular. 

Symptoms: — The onset is sudden, occurring during the night. The 
patient does not report but is reported by his comrades, when on a vessel. 
He complains of chilly sensations, but especially of headache, with aching 
in the back and the legs; fever that soon runs up, the skin hot and dry, 
the tongue coated, sometimes sore throat. There is always anorexia, 
sometimes nausea, bowels constipated. The face is of a peculiar mahogany 
color, the eyes injected, the forehead burning hot. The eyelids and lips 
may be puffy. Careful inspection will often detect slight jaundice. The 
fever may reach 105 F. on the first day; and this is the danger point. 
In the writer's cases all died who exceeded this temperature, all others 
recovering. There is little variation, except in mild cases where the fever 
does not run as high, and relaxes toward the second evening. About the 
third day the fever falls, sometimes pretty rapidly, at others slowly, and 
for one, two or three days there is a period of calm. This may be a com- 
plete intermission, or in mild cases even the end of the attack. Usually, 
however, after this comes a reactive phase, in which the fever rises, the 
stomach is more intensely irritated than during the first period, and there 
may be complete failure of renal action. The skin may then become 
intensely yellow, and this may herald the onset of this stage. In bad 
cases there is little remission, the fever remains high through it, and the 



88 YELLOW FEVER 

stomach weak or nauseated. The older writers termed this a disease 
with one paroxysm, the returning fever being, like the typhoid of cholera, 
a result of the attack rather than a stage of the malady. 

The pulse is relatively low, about ioo on the first day, falling before 
the fever does, or even while it is still rising. During the remission it may 
fall to 30. This slow pulse with a rising temperature is significant of 
yellow fever. 

Albuminuria is also significant, appearing by the third day and occur- 
ring in mild cases. In bad cases the urine may turn solid when boiled 
in the test tube. Tube casts are present in large numbers. The sup- 
pression of urine may be total. In one of the writer's cases there had 
been no secretion for two days, till a pint of champagne restored it. 

The jaundice may not appear until after death. 

The stomach is irritable from the first. The food is vomited, then 
mucus, known as " white vomit," and black vomit may not occur till the 
relapse, or on the second or third day of the attack. It consists of blood 
altered by the gastric juice. Ejected on a sheet it leaves a deposit like 
a filtrate, the colorless fluid sinking into the linen. Ecchymoses, petechias 
and mucous hemorrhages may signify the degree to which the blood has 
been disorganized. The older writers looked upon black vomit as neces- 
sarily fatal, being due to decomposition. While it is a bad omen it is not 
always fatal. The blood passes through the bowels also, appearing 
as tarry stools. Constipation is extreme, the stools being absent rather 
than retained, and not acholic. ■ 

There is sometimes active delirium, but usually the patient is quiet, 
not so much stupid as desirous of remaining quiet on account of the head- 
ache. Guiteras found his cases peculiarly alert, from the fear inspired 
by the disease. Suppression of urine causes hallucinations and may 
end in coma. These with aching of the bones prevent sleep. 

During an epidemic cases of such mildness occur that they would not 
be recognized as such were it not for the prevalence. On the other hand 
malignant forms occur in which the patient may die in a few hours. 

Convalescence may be marked by abscesses, parotid suppuration and 
diarrhea. In one of the writer's cases bulbar paralysis followed. In 
another hemiparesis followed, with a peculiar mobile state of the mental 
faculties, which gradually wore away, but were still evident ten years 
later. But in the vast majority there are no sequences; the disease runs its 
course to recovery or the grave in a week; and people in infected cities aver 
that they would "rather have yellow fever and recover than have a bad cold.' ' 

Diagnosis: — When the two coincide in prevalence it is impossible 
to diagnose between mild cases of yellow fever and bilious remittent. 



YELLOW FEVER 89 

In well-marked cases of yellow fever, the peculiar mahogany flush of the 
face, the slowing pulse with rising temperature, and the presence of albu- 
minuria before the end of the third day, are in Guiteras' opinion sufficient 
to distinguish this from all other fevers. Add to this the irritability of 
the stomach and following black vomit, jaundice, and intense headache 
with clear intellect, and the picture is unique. There is not the intense 
bone-ache of dengue, and the mortality is enormously greater. 

There is a form of malarial fever so similar to yellow fever that the 
former has received the title of malarial yellow fever. It is frequent in 
the Gulf coast cities, and under the name of Chagres fever has been and 
is destined to become still more notorious. Guiteras says jaundice occurs 
earlier in true yellow fever, but the older observers claimed it was exactly 
the opposite. The mahogany face of yellow fever is absent, also the 
albuminuria and excruciating headache. Hemorrhages and black vomit 
are rare, and the spleen is much enlarged in malarial forms, not in true 
yellow fever. Hematuria is common in malaria; there may be a history 
of that affection; and examination of the blood reveals the small ring- 
shaped organisms. The curative power of quinine is altogether wanting 
in yellow fever. 

The mortality ranges from 15 to 85 per cent. It is worse in the case 
of persons coming from the north to the tropics, and the farther north 
their origin, the greater their danger. Users of alcohol are in greater 
danger of infection and if attacked are almost certain to die. Dissipation, 
preexistent disease, all that lowers vitality, increase the gravity of the 
malady. A temperature ever so little above 105 F. was fatal in the writer's 
cases. The albuminuria is a fair indication of the gravity of the case; 
suppression of urine is most dangerous. Delirium and convulsions or 
coma depending on this cause are ominous, but sometimes they are due 
to fear, and less significant. Black vomit is, if not a fatal indication, very 
close to it. Continuance of high fever into the remittent stage is bad. 
The negro is less liable to the disease, and less likely to die of it; and 
this partial immunity extends to mixed breeds. 

Prophylaxsis: — Persons who must visit or remain in places where 
yellow fever is prevailing may escape it by observing a few simple rules: 

Keep indoors at night, in apartments well-screened, and destroy the 
mosquitoes that may be inside; the infected stegomyia being more active 
at night. 

Treatment: — Put the patient to bed, cover lightly with blankets, encour- 
age sweating and keep the stomach absolutely empty. There is no pos- 
sibility of food being digested while the stomach is so disorganized, and 
every attempt at feeding tends to induce vomiting and bring on black 



90 YELLOW FEVER 

vomit. Give enemas to wash out the colon, followed by small warm enemas 
of milk, soup or saline solution, to nourish the patient and flush the kid- 
neys. Be it remembered that the attack lasts but a few days, and that 
the patient will not starve if he gets no food for this brief period, and if 
these facts are implanted in the understanding of the nurses the patient's 
life may be saved from the useless and perilous attempts that will other- 
wise be made to feed him. Sternberg advised corrosive sublimate in 
doses of half a milligram every hour, as an antiseptic, with soda as an 
antacid. The writer does not believe the antiseptic method specially 
indicated in this malady, or that autotoxemia plays that large part in 
yellow fever it does in fevers of longer duration. The center of the 
battle is in the kidneys, and on the maintenance of their function rests the 
life of the patient. Our experience has made us exceedingly nervous over 
anything that may induce vomiting. The best results have followed a 
regime calculated to secure absolute rest to the stomach. In one case 
that recovered nothing whatever, not even a drop of water, was permitted 
to enter the stomach until the symptoms showed that the danger was 
past, which necessitated such total abstinence for seventeen days. This 
was, however, a case of unique duration. Excellent results have been 
reported from the hypodermic injection of pilocarpine, gr. 1-6, repeated 
if free sweating is not induced. This is in line with the older observations 
as to the value of sweating. Since a temperature of 105 F. seems to 
be the dead line, it would seem that there is an admirable field for the 
applications of hydrotherapy. But in all the trials made under the writer's 
observation it has failed. Others have reported more encouraging results, 
and it seems worthy of further trials. The patient does not die of hyper- 
pyrexia, however, and the fact that when a killing frost puts an end to 
the epidemic the patients then affected die, is significant. 

The irritability of the stomach may be quieted by hypodermics of 
cocaine or of morphine, gr. 1-8 of either, over the epigastrium, or by 
mustard over the pneumogastric nerve in the neck. Ice applied here is 
also effective. Pretty free hemorrhage is probably useful, but if it is 
deemed wise to interfere with it, the remedy is a hypodermic of atropine 
gr. 1 -1 34 or more. Strychnine hypodermics may be employed to sustain 
the vitality, or veratrine to relax vascular tension when excessive — 
dose gr. 3-134 to double this at once, repeated if necessary. While no 
other form of elimination can replace entirely that of the kidneys, it must 
not be forgotten that pilocarpine increases the cutaneous elimination of 
solids five times, or to half that excreted by an equal quantity of urine. 
Small exosmotic enemas of saturated salt solution, cold, also aid in remov- 
ing a part of the toxins, and by these means we may reduce the poisons 



CEREBROSPINAL FEVER 9 i 

to what the natural powers of the patient may enable him to withstand. 
This we believe to be the keynote of the treatment. 

During the epidemic of 1905 we sent a number of southern friends a 
supply of calx sulphurata, with the suggestion that saturation with it 
might prove protective against the attacks of mosquitoes and other insects. 
Every report we received has confirmed the suggestion, and we recom- 
mend the method for general trial. At the time of writing trials are being 
given on the Isthmus of Panama. 

Burggraeve quotes Vera's treatment approvingly. During the first 
period the diet is limited to acidulated drinks; blood-letting may be requis- 
ite; give emetine, clearing the bowels with sweet almond oil with lemon 
juice; tepid baths and cold compresses to the forehead, vinegar to the 
back and limbs; emollient enemas; alcohol has not given good results. 
In the second period he gives acid drinks, ice, water ices, beef or veal 
soup. In the third period he employs tonics and antispasmodics — ver- 
bena has been lauded, possibly a parasiticide. But this does not touch 
the true nature of the disease. Burggraeve advises beginning with saline, 
following with strychnine, hyoscyamine and morphine, to calm lumbo- 
abdominal pains and vomiting; fomentations to the head for excessive 
heat; then the defervescents, two or three granules each of aconitine 
and digitalin, every hour till resolution and diuresis occur; in the third 
period giving quinine hydroferrocyanate to prevent new accesses. As 
soon as possible get to a reconstituent regimen, with quassin and soda 
arsenate. 

CEREBROSPINAL FEVER 

This fever occurs sporadically and in localized epidemics; in the 
country more than in the city; more frequently in winter and spring. 
The collection of young recruits into camps seems to afford a specially 
suitable opportunity to this disease. Fatigue, mental depression and 
crowding, with other elements of bad hygiene, are the predisposing causes. 
While not apparently contagious, or transmitted by excreta or clothing, 
it depends on the diplococcus intracellularis as its prime factor. It is 
not self-protective. It lingers indefinitely in a place once attacked, but 
its transmission is governed by conditions not yet recognized. 

The diplococcus is termed intracellularis because it is found almost 
always within the polynuclear leucocytes. Malignant cases show intense 
congestion of the cerebral and spinal meninges, and a fibrinopurulent 
exudate, all most marked at the base of the brain, but extending over the 
cortex. The affection is most severe along the posterior surface of the 
cord and extends to its end. In less acute cases the meninges are hyper- 



92 CEREBROSPINAL FEVER 

plastic and the exudation is shown by yellow patches. The dilatation 
may be great. The brain may be softened, pinkish, with points of hemor- 
rhage and of inflammation. The second, fifth, seventh and eighth cranial 
pairs are most affected. The exudation is made up of a fibrinous matrix 
containing many polynuclear leucocytes. The affected nervous tissue 
is infiltrated with pus, the neuroglia swollen, with large, clear, vesicular 
nuclei. The diplococci are most numerous in the brain. They have 
been found in the nasal mucus and the lungs, where they cause a 
form of pneumonia. Ordinary pneumonia, pleurisy, nephritis and 
enlargement of the spleen have been associated with this malady 
occasionally. 

The malignant type may occur in epidemics or sporadically. It has 
a sudden onset with chills, headache, hebetude, muscular spasms, pro- 
found debility, medium fever, and a pulse feeble and slow, perhaps only 
fifty beats per minute. Petechias appear. Death is apt to ensue before 
the close of the day. 

In the commoner form, after an incubation of unknown duration the 
attack sets in with similar abruptness; headache, backache, anorexia, 
heavy chills and vomiting, fever touching 102 F., pulse full and strong, 
painful stiffness of the back of the neck. The aching increases, with 
photophobia and intolerance of noise. Children are restless. The head 
is drawn back, the back may be arched, and the pains extend to the legs. 
Tremors are present, and convulsions of the muscles of the extremities, 
tonic and clonic. The back, and neck become rigid. Strabismus is com- 
mon. The facial muscles twitch. The muscles of the eyes or face may 
be paralyzed. 

Headache is the chief complaint. The spine is sensitive to pressure 
and the skin may be hyperesthetic. Delirium may be an early symptom, 
violent or erotic, but as effusion comes on it gives way to coma. There 
is no uniform course to the fever, which is not very high, as a rule, but 
may be hyperpyretic. The pulse is also variable but apt to be remarkably 
low. Cheyne-Stokes respiration has been observed. Much importance 
is assigned to the skin affections. Herpes is frequent. The petechia? 
that give a name to the disease are commonly but not invariably present. 
Erythema, dusky mottling, rose spots, urticaria, ecthyma, pemphigus 
and even cutaneous gangrene have been observed. 

Leucocytosis is early and constant, up to 40,000 per cubic millimeter. 
Osier found the diplococcus in the blood during life. Vomiting may con- 
tinue through the course, diarrhea is less frequent, constipation being 
usual. The urine may be albuminous, increased in quantity, glycosuric 
or hematuric. 



CEREBROSPINAL FEVER 93 

The course of this fever presents many variations. Death may ensue 
in a few hours, at least half the fatalities coming within five days, or the 
malady may be protracted for months. If the patient survives the fifth 
day with improvement in symptoms, falling fever, fewer or lighter spasms 
and returning intelligence, the prognosis is good unless a relapse occurs. 
A sudden fall of the fever is bad. Convalescence is slow and apt to be 
interrupted by sequels. After bad cases recovery may be incomplete, 
and epilepsy may remain, or idiocy, for life. 

Sometimes the onset is violent, but in a day or so the symptoms sub- 
side and the attack is aborted. 

Walking cases also occur, with the usual symptoms in mild form, 
little fever or vomiting; only recognizable from the prevalence of an 
epidemic. Other cases closely follow the fever curves of malarial fevers, 
or pyemia, with great hourly perturbations. Chronic forms are frequent 
(Heubner), and may last for months, with recurring fever, varying symp- 
toms and great wasting. 

Among the more frequent complications are pleurisy, pericarditis and 
parotitis; sometimes pneumonia, multiple arthritis, serous or purulent; 
enteritis is rare. Headache, or a disposition to it on the slightest provoca- 
tion, may remain indefinitely after recovery. Hydrocephalus may follow 
in children. Aphasia also may ensue. It is the writer's impression that 
complete recovery from a severe attack is almost unknown. Partial 
recovery in one case was followed by a year of invalidism, and death at 
the end. Affections of the eye, ear and nose are due to implication of 
their nerve roots in the disease. 

Diagnostic signs are the headache, delirium, retraction of the head 
and bowed back, tremors and rigidity of the affected muscles. The slow 
pulse and moderate fever are less significant. Kernig's sign: If the thigh 
is flexed on the abdomen, the leg can not be extended on account of strong 
flexor contractures. This is probably always demonstrable in meningitis. 
But the most trustworthy evidence is afforded by lumbar puncture. A 
little chloroform may be given to a child. The patient lies on the right 
with knees drawn up and the left shoulder forward; the lumbar spinous 
processes are fixed, and the needle of a small aspirator is thrust into the 
third inter-space at one side of the median line, directed upward and 
inward, penetrating about 2J centimeters in infants, 4 to 6 in adults. 
Fluid exudes by drops, turbid, purulent or bloody in meningitis, though 
it may be clear. The microscope determines the organisms present. 
Tuberculosis may be detected by inoculating a guinea-pig. It is claimed 
that the exudate in tubercular cases contains only lymphocytes, while in 
pneumococcus and intracellularis cases the polynuclear leucocytes pre- 



94 CEREBROSPINAL FEVER 

dominate. (Cytodiagnosis.) If iodides are given, iodine may be detected 
in the former but not in cerebrospinal fever. Osier doubts both these 
assertions. 

The mortality varies from 20 to 75 per cent, being greater in children. 
High fever, coma and severe convulsions are ominous. Recovery is more 
likely if the patient survives the fifth day; but in very tedious cases there 
is probably a permanent lesion of the cerebrum. 

But little of the old treatment of this fever deserves mention — "futile," 
as Osier well expresses it. He mentions local blood-letting as sometimes 
useful; and cold to the head and spine approvingly. In one case, due, 
however, to the pneumococcus, cold was applied continuously for weeks; 
the patient was saved by it, but after a year of suffering finally died. If 
used at all it should be applied very cold, with due intervals to prevent 
harm from the action of the cold on the tissues. A case was reported in 
which great relief was experienced from the application of hot water 
on cloths, so hot as to scald the nurse's hands, and continued till the 
malady had subsided. This case was not verified by modern scientific 
methods, and must be taken with that grain of salt. Unless the tempera- 
ture is higher than usual it is difficult to see what benefit is to be expected 
from hydrotherapy, which is recommended automatically. Counter- 
irritation is not equal to applications of heat and cold, and should be 
reserved for the stage of convalescence when there may be effused material 
to be absorbed. Then four lines may be drawn along the spine with a 
crayon of silver nitrate (the skin previously wet), half an inch apart. This 
is the most effective and least painful method. Some benefit seems to 
follow lumbar punctures. Everyone recommends opiates, morphine 
hypodermically; and if we can not cure we might as well give what relief 
we can. There is no evidence that the huge doses of iodides, bromides, 
quinine, ergot and chloral so freely used of late possess any beneficial 
properties whatever. There is more reason in the maximal use of mercury, 
yet it has no clear evidence in its favor. 

The resources of active principle therapy have not yet been drawn upon 
in treating cerebrospinal fever. But it can do no harm to empty the 
bowels with calomel followed by saline laxatives, and disinfect the stools 
by giving zinc sulphocarbolate, gr. 2 1-2 to 5 every two hours. Sthenic 
fever is controllable by the defervescent triad, every quarter to one hour 
as required; for asthenia substituting the dosimetric triad in similar doses. 
It is worth while to try if an attack may not be broken at the outset by 
a full dose of pilocarpine, gr. 1-6, hypodermically, repeated hourly till 
free sweating or salivation results. The effects of nuclein in full doses, 
and of saturation with calcium sulphide in other maladies have been so 



CEREBROSPINAL FEVER 95 

good that they deserve a trial here. The acknowledged failure of former 
methods imperatively demands striking out in new directions, instead 
of turning over the same old muck-heaps uselessly. Solanine may prove 
a valuable sedative here; pushed to full effect. 

During convalescence there is need of the tonic roborant regimen, 
with absorbents continued many months. The iodides of mercury, iron, 
arsenic and gold, may be alternated or combined, according to the indica- 
tion. Iodoform may be a useful addition, when there is cough, or abdomi- 
nal pain. 

Other remedies may be indicated by special symptoms. 

Gelsemium has long enjoyed considerable popularity in some 
sections as a remedy for all forms of meningeal inflammation. The 
uncertainty of the ordinary fofms in which it was presented has deterred 
many from giving this agent a fair trial. The alkaloid gelseminine is now 
accessible in a state of purity and uniform strength, and may be utilized. 
As compared with veratrine and aconitine, gelseminine presents a max- 
imum of cerebral sedation with a minimum of circulation depression. This 
would render it especially suitable for a malady where there may be but 
little fever and a slow pulse with a fatal encephalic inflammation. The 
adult dose of gelseminine is 1-250 grain, and as this alkaloid is very 
quickly absorbed and eliminated, the dose should be repeated every 
fifteen to sixty minutes, according to the acuteness of the symptoms, 
until the cerebral irritation shall have subsided or the characteristic drop- 
ping of the eyelids shows that the full therapeutic effect has been 
obtained. Beyond this point there is no benefit to be had, and the 
remedy should be discontinued or given less frequently. 

Another agent that deserves retrial is conium. No drug of the older 
pharmacopoeia is more notoriously untrustworthy than this. Freshly 
prepared succus conii may afford some useful effects; but though the plant 
possesses undoubtedly valuable properties it has fallen into almost complete 
disuse on account of the variability of even those preparations that some- 
times manifest activity. We have now, however, in the hydrobromide 
of the alkaloid cicutine, an agent possessing all the therapeutic values of 
the plant, uniform in strength and retaining its powers unaltered when 
made into granules. As a sedative in nervous unrest and cerebrospinal 
irritations and inflammations, cicutine hydrobromide grows in favor most 
rapidly with those who make the most general use of it. The adult dose 
is 1-67 grain, and this should be repeated every quarter-hour, half-hour, 
or one, two, or three hours, according to the conditions present and the 
effects. Muscular weakness and vertigo indicate the beginning of toxic 
action, beyond which this remedy should never be pushed. Usually the 



96 CEREBROSPINAL FEVER 

desired relief occurs before such toxic effects appear. As cicutine raises 
vascular tension and the body temperature, it is obviously not suitable 
for cases showing fever and evidences of sthenic inflammation. 

Cicutine and gelseminine are synergistic and may be administered 
together when both are indicated. They are suited to the asthenic forms, 
with low fever and slow or weak pulse. If the fever is asthenic or the 
eliminants sluggish, veratrine will be a better selection; while for doubtful, 
median forms aconitine offers a nicely appropriate remedy. Photophobia 
is an indication for cicutine which notably relieves this symptom. 

The indications clearly dominating the treatment of this terrible malady 
may be stated as : — 

The alimentary canal to be thoroughly cleared and rendered as nearly 
aseptic as possible — calomel, saline laxatives, zinc sulphocarbolate, each 
in appropriate dosage. 

The utmost sedation compatible with the patient's condition— gelsem- 
inine and cicutine hydrobromide for asthenic, aconitine or veratrine for 
sthenic forms; either pushed to full effect. 

Possibly breaking up the attack at the outset by full dosage with 
pilocarpine, or stopping the microbian action by saturation with calcium 
sulphide, as early as possible — it is one thing to stop the damage; another 
to repair it. 

The patient's strength to be sustained from the first, not by a senseless 
pouring in of food he is unable to digest and assimilate, but by the most 
judicious and scientific feeding, massage, bathing, fresh air, and especially 
by the use of nuclein in full doses to reinforce the leucocytes and innervate 
them in their life and death struggle with the microbes. 

The moment the acute malady has subsided the absorbents should be 
put to work to remove the debris before it has become organized or done 
more damage than compress the nerve structures. The writer presents 
the following as the most speedy and powerful absorbent combination he 
has as yet made trial of — one far superior to the ancient " corrosive sublimate 
and iodide:" Mercury biniodide, 1-67 grain; iodoform, J grain; phyto- 
laccin, J grain, of each three granules; arsenic iodide 1-67 grain, one granule; 
these ten to be taken together four times a day, one daily dose being added 
every two or three days until evidences of iodism or conjunctival irritation, 
or perhaps of mercurialism, though this we have never yet seen, show 
that the toxic point has been touched, when the doses must be slightly 
decreased and the remedies held as closely as possible to this point for 
weeks or months. 

The treatment herein recommended is founded on the pathology of 
the disease and the known action of the remedies suggested. The old 



INFLUENZA 97 

treatment had only an empiric foundation, and has failed completely. 
Not a single remedy as yet proposed has approved its value in practice. 
Serums offer little chance of success in dealing with a malady that may be 
caused by any one of a number of different microorganisms, 

INFLUENZA 

The pandermic prevalences of this malady are for years followed by 
endemic outbreaks in various localities over which it has passed. It is 
noted for its protean manifestations. It lasts in any one place about two 
months, during which few escape. While it kills few directly, during its 
prevalence many die of other affections so that the death-rate is very high. 
Many chronic invalids die when this is added to their maladies. 

The cause of influenza is now acknowledged to be the bacillus discovered 
by Pfeiffer. This is not the cause of the ordinary colds often mis- 
named influenza. True influenza is very contagious, spreads as fast 
as man can travel, occurs at all seasons and is not self -protective. 
Few are immune. 

Pfeiffer 's bacillus is a small, non-motile organism, staining well in 
Loeffler's methylene blue and in a dilute pale-red watery solution of carbol- 
fuchsin, grows only with hemoglobin, and is present in enormous numbers 
in the nasal and bronchial secretions of those affected. How long it persists 
there after the attack has subsided is not known, but it may be found for 
years. Malaria is less prevalent during influenza epidemics. Osier does 
not believe that animals are attacked epidemically at the same time as men. 

The incubation lasts one to four days. The attack is abrupt, with fever 
and the other symptoms. In the respiratory type the bacilli invade the 
whole of that mucous tract. The attack resembles an acute coryza, with 
unusual debility — a worse cold than usual. Bronchitis develops with 
fever, delirium and prostration approaching the typhoid type. Pleurisy 
or pneumonia may ensue. The sputa may be profuse and serious, greenish 
yellow and nummular, or dark red and bloody. Diffuse bronchiectasis 
may result. The malady may extend to the finer bronchioles and present 
capillary bronchitis with cyanosis and dyspnea. The pneumonia may be 
purely influenzal or mixed with pneumococcus. The former is usually 
catarrhal. The course is irregular, the disease often masked. Pleurisy 
is less frequent and apt to end in empyema. Preexisting tuberculosis is 
aggravated. 

In the nervous form we have suddenly presenting headache, pains in the 
back, legs, or any part, intense in character, with profound prostration. 
Acute inflammations of the nervous substance may cause paralyses, or 



98 INFLUENZA 

any form of neurosis may be presented. The heart is often disordered. 
Mental aberrations may follow. 

Sometimes the force of the maiady is expended on the stomach and 
bowels, with the same violent and sudden outbreak, intensity of pain and 
other symptoms, and great prostration. Jaundice, enlargement of the 
spleen and collapse are noted sometimes. 

There is a febrile form lasting weeks, remittent, irregular in type, with 
chills simulating malaria, or continuous like typhoid. 

Many other forms might be described, as the force of the disease is 
exerted on the kidneys, bladder, brain, testes, heart, uterus and ovaries, 
eyes, ears or other organs. Herpes, erythema, purpura hnd other skin 
affections are seen. Vertigo may be a sequel. Many persons date their 
invalidism from influenza, which has left behind it a train of ailments with 
debility that is with difficulty relieved. Sometimes influenza seems to 
simulate another disease that is prevalent. 

The diagnosis is easy, if everything occurring during an epidemic is 
ascribed to influenza. And in truth, everything seems to be tinged or 
influenced by it. The suddenness and violence of the attack, the suffering 
out of proportion to the apparent malady, and above all the loss of tone and 
profound vital depression, indicate this affection. Discovery of the specific 
bacillus confirms a diagnosis already made. 

Isolation is impossible and useless in an epidemic. Disinfection of the 
excreta is unavailing in a malady whose germs can be found in the sputa 
for years after the attack. There have been given tons of quinine, 
other tons of ammonias, other tons of coal-tars, and when a serum 
comes along tons of it will be given, with as high hopes and as great 
initial enthusiasm. But up to the present no remedy has proved of 
actual, unmistakable value in checking the disease, shortening the attack, 
or influencing its termination. Possibly Raspail's camphor was better 
than any later fad. 

TreBtment .* — We must go on general principles, applying the treatment 
that has given the best results in fevers of other forms. While strychnine 
is exceedingly useful, the tendency to push it too strongly must be avoided, 
it seems natural that in a disease whose principal manifestation is weakening 
of general tonicity, universal relaxation, this greatest of function incitors 
and tissue stiffeners should be indicated in quantities to meet the need. 
But there is also in influenza a deficiency in irritability, and very soon we 
see exhaustion, which is quickly followed by toxic symptoms from even 
moderate doses of strychnine. The writer has been compelled to lay aside 
this powerful weapon and substitute the weaker brucine, in doses of gr. 1-67 
every one or two hours, in some cases. 



INFLUENZA 99 

The same may be said of other drugs; be careful in giving large doses, 
for toxic effects may be caused by moderate doses of any of them. Nowhere 
is the importance of the delicately accurate system of minimal cumulative 
dosage instituted by Burggraeve better demonstrated than here. 

Leave out the coal tars. The alkaloidal combinations will go far in 
subduing fever and assuaging suffering. Beyond this rely as much as 
possible on heat. The hot bath and hot water-bag, skilfully applied, will 
be of immense benefit. All anodynes are objectionable. Opiates are 
sometimes deadly; alcohol has been fully tried and found absolutely useless 
and dangerous, increasing vascular and nervous relaxation and further 
depressing the vital forces. All the benefit obtainable from it is better 
secured from hot capiscum tea, with a few drops of tincture of camphor. 
Of course men would prefer punch, but we are talking of medicine, not 
catering to depravity. 

Various combinations of ammonia salts have been used as means of 
relieving suffering; and some benefit may be allowed them. There is no 
specific virtue in any of them; they do not act as antacids for there is no 
acidity to counteract. The benefit is due to momentary stimulation, and 
this is soon past, and their continued use is a disadvantage and a cause of 
debility — quickly induced in influenza. We may find better remedies 
among the so-called antispasmodics, to which group ammonia belongs. 
Camphor has been mentioned, and musk, castor, valerian, asafetida and 
sumbul each possesses some power of relieving suffering and sustaining the 
vital forces in this malady. For convenience the writer prefers the valer- 
ianates, and gives caffeine valerianate in doses of gr. J frequently repeated. 
Small doses — but we are dealing with a disease in which the dosage can 
not be too delicately adjusted. Atropine valerianate, gr. 1-250, is more 
powerfully anodyne and is sometimes useful, especially when there is free 
sweating or special respiratory debility. Strychnine valerianate is also 
useful, and would be substituted for the arsenate but for a lingering hope 
that arsenic may possibly exert a germicidal action upon the bacilli. 

For joint pains, give quinine salicylate gr. J every half hour. Again 
small doses! But eight grains a day is not homeopathic in minuteness, 
and some of us need an object-lesson on the principle of the constant 
infiltration of a remedy into the blood by this cumulative dose system. It 
acts like the oil that quiets waves, by preventing the beginning of wave 
formation. 

Rest in bed as long as the depression lasts; rich, highly nutritious foods, 
easily digested, turtle soup, clam broth, raw oysters, and eggs, warm milk, 
predigested foods, fresh fruit juices, coffee, best in small quantities frequently 
repeated every two hours, and pushed to the limit of the digestive capacity. 

LOfC. 



ioo INFLUENZA 

Gentle massage, rubbing warm cod-liver oil or goose-grease into the skin. 
Hot salt baths and rubbings. Change of air to seaside or mountain, with 
simple bitters and iron during convalescence. From its properties as a 
contracter of connective tissue, berberine may be preferable to other bitters; 
gr. J every two hours during the waking hours. 

Thus far we are carried by experience. We still await the specific for 
influenza, the germicide that will pursue the bacillus into the blood 
channels and conquer it there. Possibly nuclein may be of benefit; and it 
should be. given in full doses, as one remedy that will not exhaust suscep- 
tibility. 

Persons suffering with influenza or convalescing from it, are peculiarly 
liable to autotoxemia, and depressed by it in their mental faculties as well 
as their physical functions. Many a suicide might have been prevented by 
salines and antiseptics. 

Laura says the principle indication is to combat the infectious element, 
and at the same time to relieve and sustain the general forces of the poisoned 
organism; in particular to correct and reestablish cardiac strength. For 
even in pulmonary localizations of the infectious maladies, one dies of 
cardiac rather than of pulmonary paralysis. The remedies that sustain 
the nervous forces and cardiac energies are also those capable of sustaining 
the life of the lung and restoring it to a normal state. 

Pleuropneumonia is the gravest complication of infectious maladies, 
especially of la grippe, which, by its toxins, gives to the ailment its asthenic 
and adynamic inpress, and ,by its multiple localizations augments the 
dangers and necessitates a therapeusis energetic and complex. Against the 
toxins the best remedy is calcium sulphide, especially in respiratory forms 
where it also combats the association of other pathogenic microbes and 
catarrhs, especially fetid forms. With this may be associated the benzoates, 
salicylic acid and iodoform. High temperatures are met with aconitine. 
Quinine arsenate and hydroferrocyanate are useful for remitttent and 
intermittent fever. In all asthenic and adynamic forms of fever quinine 
is a truly precious tonic and cardiac. The physician finds in digitalin and 
strophanthin two powerful cardiocynetics, and their association is completed 
by adding strychnine, which in all morbid asthenic and adynamic forms 
should never be forgotten; for it constitutes the most prompt and powerful 
general therapeutic dynamogene of the nervous energies. When it is 
necessary to arouse suddenly and urgently the nervous forces of the heart, 
we must have recourse promptly to caffeine, a rapid excitor of the heart 
and advantageous also through its prompt diuretic effect. When the urine 
grows scanty, anuria should be carefully combated to prevent insufficiency 
of elimination and depuration of the blood. Follow caffeine with other 



INFLUENZA 101 

cardiants, as its action is transitory and passing, though useful from the 
particularity of its clinical application. The doses should be proportioned 
to the case; the granules employed, or hypodermic injections in urgent 
cases. Tolerance is proportionate to the degree of asthenia and adynamia 
present. In the frequent hemorrhagic forms of la grippe ergotin is indicated 
in sufficient doses, frequently repeated. Cleansing of the stomach and 
bowels, especially in gastrointestinal catarrh is secured with benefit by using 
saline laxative by mouth or rectum. In hyperpyrexia add applications of 
cold water. To the drug therapy it is absolutely necessary to add a wise 
hygienic therapy. All cases of this malady require absolute rest in bed, 
even the mildest, to avoid the supervention of grave symptoms or perilous 
localizations. The diet should be liquid, but restorative and tonifiant — 
milk, bouillon, cocoa, eggs, old wine, tonic beverages. The air of the sick- 
room should be changed incessantly; nothing being more dangerous than 
the air of a room charged with exhalations from an infected body. The 
doctor must combat vulgar prejudices against drafts, which leave the sick 
man enveloped in a pestic milieu, no less hurtful than the disease and often 
much more dangerous. The sick-room should be the largest of the dwelling, 
the bedding frequently changed unless weakness of the patient forbids. 
During convalescence the arsenics, irons, glycerophosphates, animal diet, 
the country. Scrupulously following the methods indicated, life is saved 
and convalescence abridged — often dragging along after the physician 
has left the patient to himself. The physician if he does not pose as 
dominus, must never forget that at least he is the minister. Therapeutic 
nihilism in grave maladies is a crime. 

Monin says that when the microbian virulence is very marked, or when 
the nervous prostration (from the overpowering force of the attack, or 
from preexistent infections, or organic lesions) enfeebles the individual 
resistance, we then see installed the malignant forms of influenza, the 
powerful microbian associations, infections superadded or aggravated 
by the biosthenic bankruptcy. It is then that one observes rachialgia, 
delirium, typhoid symptoms, profound or extensive pulmonary conges- 
tions, pleuropneumonias, tachycardia, myocarditis, etc. La Grippe 
possesses the singular property of arousing previous conditions that 
appeared to be cured; not tuberculosis, which often merely sleeps, but 
angiocholites, arthrites, cerebral affections, metrites and urethrites. His 
treatment begins by confining the patient to bed, or at least to his room; 
clearing the alimentary tract by a saline; light liquid diet, hot soups, 
weak grog, fluids pushed to toxin-elimination. For thoracic congestion or 
tendency to hemoptysis he applies dry cups to the chest and sinapisms 
to the thighs. The primary therapeutic indications are the fight against 



102 INFLUENZA 

the infection of the blood, and the depression, often remarkable, of the 
nervous system. For this he advises the ' antizymotic ' granule, which 
contains brucine, gr. 1-134, quinine hydroferrocyanate, gr. 1-12, calcium 
sulphide, gr. 1-6, and aconitine cryst., gr. 1-500. This sufficiently pushed 
as to dosage will meet the gravest symptoms; even neutralizing the toxic 
effects of the grippal poison on the great sympathetic and the pneumo- 
gastric, and extricating many times the influenzal from collapse, cardiac 
arrhythmia, bradycardia, agrypnia resisting all calmants, etc. In ordi- 
nary cases it suffices to give one of these granules every hour during the 
first days, and in grave and alarming forms one every half-hour for four 
hours, and then every hour. These granules possess a manifest anti- 
pyretic and neurosthenic activity, and stimulate to the highest point 
microbian elimination. Their puissance bursts forth especially in the 
face of nervous manifestations so characteristic of influenza, suppressing 
orbital headache, nocturnal agitation, polymorphic neuralgias, and 
promptly remedying that invincible lassitude, that strange enervation of 
the forces, to make place for the most salutary general reaction. When 
the thoracic manifestations persist nothing goes so well as calcium sul- 
phide, for the painful erythematous angina, and the persistent paroxysmal 
cough and retrosternal dyspnea due to laryngotracheal grippe. The 
disengaged sulphydric acid, acts also against the bronchial infection, and 
may jugulate grippal pneumonia and pleurisy; the neutralizing effect 
of this antiseptic gas being exerted on the pneumococcus and strepto- 
coccus in the pulmonary alveoli, where the gases of the blood are inter- 
changed. This treatment causes the grippal state to quickly pass on to 
convalescence, usually marked by profuse sweats, notable polyuria or 
herpetic eruptions. If the patient is kept under the mild influence of 
the sulphide and the antizymotics, la grippe will not be "that malady of 
relapses, recrudences and surprises," the cause of so many mischances. 
For by this we do not permit the bacterial toxins to perpetrate on our 
most noble cellular elements their anatomic or functional lesions; we 
abridge that valetudinarian state that by prostration and cerebromedullary 
languishing comes so voluntarily into grippal neurosthenia. It is by 
active opening of emunctories as well as by reabsorption and elimination 
of necrosed elements that the dosimetric treatment installs convalescence 
as frankly particularly so noted by all observers. While some retrograde 
spirits continue to look on the war for organic defense as a chemical equa- 
tion and persist in their disastrous practice of seeking to destroy directly 
the pathogenic agent, dosimetry has known how to elevate the problem 
and proclaim the necessity of exalting the vital resistance, which alone 
is capable of rendering the microbe inactive, by supplying him an environ- 



DENGUE 103 

ment improper for his proliferating prosperity. By putting in play our 
natural forces of elimination and destruction, in exalting phagocytosis 
or positive chemotaxis, the granules take with our cellules an active part 
in the antitoxic warfare; they excite the leucocytes against their invaders, 
until victory is incontestable. There then remains (through the banalities 
of hygiene and the tonic regime) only to repair the breaches which during 
the assault have been produced in the organic fortress. 

DENGUE 

Dengue is a disease of the tropics, spreading to semi-tropical countries 
in epidemics. It is as pandemic as influenza, few of an infected community 
escaping. It is most frequent in the West Indies. Epidemics travel 
along the routes of trade and by ships. Arriving at a city, nearly every 
person is attacked, and in two months the epidemic has run its course. 
If dengue spreads beyond its usual limits it is in the hottest part of the 
year, and the epidemic is stopped by frost. Dryness of season has no 
influence. It clings to the coast but will invade the interior and ascend 
the highlands on occasion. 

The attack may be heralded by some hours' malaise, headache or 
rheumatic pains; or it may begin abruptly. Pains and fever set in with 
the greatest severity, or chilliness occurs, or deep flushing of the face. 
Fever rises rapidly, the head and eyes ache; and some parts of the body, 
muscles, bones or joints, ache with such severity that the name of " break- 
bone fever" is well earned. The loins ache, the face about the eyes grows 
purplish, the skin and mucosa are flushed and erythematous. Within 
a few hours the patient is helpless, pulse 130, temperature 103 to 105 F. 
or more, with intense headache, unable to move for pain, and prostrated. 
The skin is hot and dry, the tongue coated, the stomach oppressed or sick. 

The fever touches its highest point the first day, and on any day sub- 
sequently the symptoms may begin to subside. Or, on the second day 
crisis may set in with profuse sweating, diuresis, diarrhea or epistaxis. 
Relief is immediate. The erythema also disappears. Whether the fall 
is by crisis or lysis great comfort ensues, and there is an intermission in 
which the fever is gone and the patient may be up and about. This may 
be permanent, but on any day from the fourth to the seventh from the 
first attack a relapse may occur, with more or less of the symptoms of the 
first paroxysm. It is usually lighter, however, but with it is seen a roseolar 
eruption which may persist for several days after the fever has subsided. 
Desquamation follows, similar to that of measles. As the relapse breaks 
up the temperature may become subnormal. 



104 DENGUE 

The eruption may be absent. It begins on the hands and extends 
up toward the elbows, with prickling and tingling, then appears on the 
back, chest, upper arms and thighs, as discrete red-brown spots, round, 
slightly elevated, up to one-half inch in diameter. By enlarging they 
coalesce into irregular patches. The whole skin may be covered. The 
hands, wrists, elbows and knees are most affected. It disappears on 
pressure. It fades as it appeared. Desquamation may continue for 
weeks, with intense itching. 

Convalescence sets in at once and in a few days the patient is back 
at his business, but the pains may continue for a longer time, or recur 
suddenly in some joint or muscle. The knee is most frequently affected, 
then the wrists and shoulders. The soles of the feet and the tarsus are 
often affected. The malady may persist until the muscles atrophy from 
disuse. The pains may be difficult to locate, the muscles and joints 
being movable and handled without suffering. They are worse on rising 
or on moving after rest. Rest and heat relieve. Passive motions are 
painless but resistance to motion causes acute pain. A sense of powerless- 
ness accompanies the muscular pain. 

During convalescence the patient may also suffer from anorexia, 
debilky, insomnia, febriculae, pruritus, urticaria, lichen, papules, adenitis, 
orchitis, cardiac inflammations, purpura, hyperpyrexia, mucous and 
uterine hemorrhages, or albuminuria. Pregnant women do not as a rule 
abort. 

There seems to be much variability in the types of different epidemics. 
Some describe swelling of the joints, metastases, melancholia, etc. But 
the essentials are present, in a sudden rise of temperature, initial erythema, 
pains in limbs and joints, and a rosy eruption in the relapse. 

Immunity does not exceed a year. 

The incubation is from a few hours to three days, rarely more. 

Death rarely occurs, except to young and feeble infants or aged and 
infirm victims of chronic ailments who were struggling on the verge of 
the grave before this affected them. Delirium and convulsions are bad 
omens in infants. Hyperpyrexia with pulmonary edema followed by 
coma sometimes occur. The malady lowers the vital forces, however, 
and many fall victims to other maladies which they might otherwise have 
withstood. 

Few autopsies have been reported. The only morbid anatomy men- 
tioned was inflammation of the lungs and meningitis. 

Dengue may be confounded with scarlatina, measles, roetheln, syphi- 
litic roseola, influenza, rheumatism or malaria. The existence of the 
epidemic, the rash and peculiar pains will usually suffice for diagnosis. 



THE PLAGUE 105 

For the pains give quinine salicylate, gr. 1-6 every half-hour, and 
caffeine valerianate in similar closes. Atropine valerianate, gr. 1-250 
may be added until the mouth begins to feel dry. Hot packs, salt baths 
and rubbing, and hot water-bottles, will aid in giving relief without opiates, 
which are to be avoided if possible as their ulterior effect is injurious. 
In no infectious fever can it fail to be harmful to lock up the excretions 
within the sick man's body. 

During convalescence the arsenates of iron, quinine and strychnine, 
with quassin or berberine, and the resources of the reconstructive regime, 
are indicated. 

No specific treatment of dengue has yet been discovered. 

THE PLAGUE 

A specific, inoculable and otherwise communicable epidemic disease, 
common to man and many of the lower animals; characterized by fever, 
buboes, rapid course, high mortality and a specific bacterium in the 
lymphatic glands, viscera and blood (Manson). 

The reader will do well to secure a copy of Defoe's "History of the 
Great Plague in London." He will find it the finest account of any 
plague extant, of absorbing interest. Though not written by a physician 
and not historical, the account given is substantially correct. 

While the development of American interests in the East and the 
opening of the Panama canal may be expected to render the plague of 
more direct interest to us in the near future, the gradual retreat of the 
malady and the circumscribing of its epidemics by the application of* 
practical hygiene are rendering this affection rarer and its extinction is 
within reach. 

The specific cause is a coccobacillus, discovered by Kitasato. It is 
found in the buboes at first alone, but later with pyogenic organisms. 
It also appears in most of the oigans, the blood, and in the pneumonic 
form swarms in the sputa. It resembles the germ of chicken cholera, 
being short and thick, with rounded ends, is actively motile with a ter- 
minal fiagellum (Gordon). It is readily stained by aniline, the ends 
more than the middle. It does not form spores (Kitasato). 

The best temperature for culture is between 36 and 39 C. Plague 
is almost certainly inoculable in man, as it is in the lower animals. Rodents 
are always killed by the inoculated disease, birds survive, monkeys are 
readily affected, sheep and swine slightly if at all (Lowson). Dogs are 
readily infected. Late in the attack the pus is so much reduced in virulence 
that it has been conjectured that pyogenic organisms destroy the pest bacilli. 



106 THE PLAGUE 

The observations made in New Zealand strongly favor the view that 
the plague is not directly contagious, but that the bacilli are transferred 
to animals like the rat, by insects; and that if the access of fleas, and 
probably flies, is prevented there will be no spread of the malady. The 
extermination of the rat is now looked upon as the most important of 
prophylactic measures. While bad air and overcrowding have their 
influence as in most epidemic maladies, it is by lowering the vitality, 
and affording opportunities for insect transference, rather than by direct 
contagion. There is less evidence in favor of the older ideas as to trans- 
mission of infection through air and the survival of bacilli in soil. When 
a disease is acknowledged to affect rats, mice, dogs, flies and fleas, and 
may affect bedbugs and other insects, it is difficult to exclude such methods 
of direct transference; and we believe there is no known case of con- 
tagion where such transference has been absolutely prevented. Even 
in Bombay physicians and nurses have been rarely attacked. 

The virulence of the bacilli may be increased or mitigated. Defoe 
noted that the earlier cases were uniformly fatal while those occurring 
toward the close of the epidemic were much less dangerous. Virus passed 
through a succession of guinea-pigs becomes more rapid in its action. 
Yersin found that when cultivated on gelatin-peptone some colonies 
developed quicker than others, and that if inoculations were made from 
the colonies first developed the virulence was less than from the others, 
so that in time they ceased to be fatal to guinea-pigs. 

Rodents fed on plague-infected material die of that disease. v 

Mice inoculated with plague were placed with others not inoculated; 
the first died soon and the others later; proving transfer of the malady 
by contact — or by parasites. 

It is difficult or impossible for plague to spread in districts subject 
to good sanitation; while in the domains of filth and overcrowding it 
spreads like wildfire (Manson). 

Open wounds are apt to become infected. Post mortems are safe 
if no wounds are made. Infected food and drink will convey the disease. 
Many infections occur through small wounds of the feet coming in con- 
tact with infected earth — or with fleas that have left the bodies of dead rats. 

Symptoms: — The incubation varies between two and eight days; 
very rarely extending to fifteen. During the period of greatest malig- 
nancy it has been claimed that this period may be shortened to three or 
four hours. 

In a few cases prodromes have been recorded, malaise, melancholy, 
anorexia, chilliness, giddiness, palpitations and dull pains where buboes 
are developing. Griesinger mentioned also lumbar pains. 



THE PLAGUE 107 

The attack is more often abrupt, with depression extending to collapse, 
fever, profound toxemia, headache, usually frontal, sometimes occipital, 
aching limbs, vertigo, drowsiness or insomnia, broken dreams. Rigors 
are rarer than chilly sensations. There may be a sense of weight in the 
head, like that from inhaling coal gas (Griesinger); the face is drawn 
and haggard, eyes red, sunken and staring, pupils often dilated; the face 
may wear a look of horror or fear. The patient, if he can walk, drags 
himself about in a dreamy way, or staggers about. There may be nausea, 
vomiting, or diarrhea. The speech is heavy and stuttering; the senso- 
rium dulled, with tremors, sense of internal heat, and injection at the inner 
canthus. These symptoms may last a few hours, several days, or be absent. 

The fever may set in abruptly or follow the above. The temperature 
rises to 103 to 107 , the pulse and respiration rising commensurately. 
The rise is slower than in malaria. The skin is dry and burning, face 
swollen, eyes more injected, sunken and fixed, hearing dull. The tongue 
is swollen and heavily furred, soon turning black, while sordes form about 
the teeth, lips and nostrils. Prostration is extreme, the patient being able 
only with difficulty to make known his tormenting thirst. Noisy delirium 
may follow; more frequently he sinks into typhoid stupor, picking at the 
bed-clothes. Coma, convulsions, perhaps tetaniform, retention of urine, 
subsultus tendinum, etc., may follow. Vomiting may be present, consti- 
pation or diarrhea, the liver and spleen are enlarged, the urine is scanty 
but rarely shows more than a trace of albumin; the pulse loses its fullness, 
becoming weak, small, fluttering, dicrotic or intermittent. The heart 
dilates later, the first sound growing obscure, and cyanosis may precede 
death. Griesinger speaks of a painful sensation of heat in the epigastrium, 
not quieted by fluids. Stupor becomes prominent on the second or third 
day. Hematuria may occur, or total suppression of urine. Bronchitis, 
epistaxis, wild furious delirium, are occasional features. 

The buboes may develop at any time from the first to the fifth day; 
Griesinger says from the second to the fourth day. In 70 per cent of the 
cases they appear in the groin, usually the right, affecting one or more of 
the inguinal glands; in 20 per cent it is in the axilla, in 10 per cent (mainly 
in children) in the gland at the angle of the lower jaw. There is usually 
but one — in J of the cases they are developed on both sides, symmetrically. 
Occasionally they are found in the popliteal, epitrochlear, or in the other 
cervical glands; or in several locations at once. The buboes vary in size 
from a walnut to a goose-egg; they may be very painful or but slightly so; 
they are surrounded by brawny infiltration. Carbuncles or local areas of 
gangrene sometimes follow the buboes, on the legs, neck or back; they 
may spread and destroy large parts of the skin, etc. 



108 THE PLAGUE 

In favorable cases the fever and other symptoms moderate as the buboes 
appear or as they maturate; free sweating occurs, the tongue moistens, 
the pulse slows and fever subsides, delirium abates. The swellings soften 
and discharge offensive pus, or very slowly resolve. The gangrene is demar- 
cated, urine becomes free, and convalescence commences from the sixth 
to the tenth day. Local secondary suppurations may occur, or the buboes 
heal sluggishly. The typhoid state may continue till the end of the second 
or even the third week. Or another stage may develop, with irregular fever, 
parotid suppurations, malaria and other evidences of septicemic invasion. 

Hemorrhages are frequent features — ecchymoses of various sizes, 
vibices, bleeding from the nose, mouth, lungs, stomach, bowels or kidneys. 
Some epidemics are especially hemorrhagic. Hemoptysis and pneumonia 
mark unusual malignancy. Pregnant women abort, the fetus showing 
evidences of the infection. Death may ensue at any stage, from collapse, 
heart-failure, coma, convulsions, hemorrhages primary or secondary, 
or exhaustion. Convalescence may be quite rapid, or slow and interrupted 
by suppurative sequels. 

In the pestis siderans the system is overwhelmed at the outset by the 
intensity of the infection, and death follows in a few hours. Pneumonic 
plague is specially formidable on account of the mortality and the spread 
of infection by sputa. The attack commences like an ordinary pneumonia, 
with rigors, malaise, intense headache, vomiting, general aching and fever; 
followed by cough, dyspnea and profuse thin blood-tinged sputa. Mucous 
rales are heard at the bases of the lungs, respiration is hurried, delirium 
supervenes with evidences of the gravest prostration, and death ensues 
about the fifth day. Direct primary infection of the respiratory mucosa 
is here present. The physical signs may be limited to one or more lobes. 
The bacilli are found early in the sputa. Recovery is exceedingly rare 
in this form of plague. 

Abortive forms occur in all epidemics, becoming more frequent toward 
the close. The buboes may be attended with little constitutional disturb- 
ance and are apt to undergo resolution. Sudden collapse has been noted. 
Similar epidemics of bubo may precede or follow true plague; whether 
these are due to the plague infection always is not determined. 

The mortality varies in epidemics; it is greatest at the beginning; the 
total rate being from 60 to 95 per cent. At Hong Kong the mortality among 
Chinese was 93.4 per cent, among Indians 77 per cent, Japanese 60 per 
cent, and Europeans 18.2 per cent, this corresponding closely to the ability 
of each class to secure skilled care and hygienic surroundings. 

Pathology: — Ecchymoses are frequently seen at autopsies, especially 
at the sites of insect bites. In severe epidemics subcutaneous extravasations 



THE PLAGUE 109 

are so prominent as to have given the malady the name of 'black death. ' 
This title has also been attributed to black masses of clotted blood expec- 
torated in the pulmonary form. Boils, pustules and abscesses may be 
present. Rigor mortis is slight. Post mortem muscular contractions and 
rise of temperature have been noted. Decomposition commences soon. 

The brain, cord and meninges are congested, their fluids increased, 
cerebral sections show numerous bloody points, extravasations into the 
brain substance are seen. Serous ecchymoses are common and the serous 
fluids tinged with blood. Bronchitis and hypostatic congestion are frequent; 
less so are infarcts and pulmonary abscesses. The right heart and great 
veins are distended, the blood not firmly clotted. The liver is enlarged, 
its cells degenerating, the spleen over twice its normal size; the intestinal 
mucosa congested, ecchymotic, eroded, and ulcerated about the ileocecal 
valve; similar conditions obtain in the kidneys, the internal and external 
surfaces, while the surrounding tissues are congested; the ureters and 
vesical mucosa studded with ecchymoses and the urine contains blood. 
One or many lymphatic glands are swollen and congested; in and about 
them we find exudations, hemorrhagic effusions, glandular hyperplasia 
and enormous numbers of bacteria. The vessels connecting superficial 
and deeper glands are affected. The hyperemia in and afound buboes is 
intense at all stages of the disease; the tendency to hemorrhages marked. 
At first the specific bacilli are found in the perifollicular lymph-spaces; 
later they are in the follicles and medullary cords. The lymphatic glands 
may be generally but mildly affected. 

Diagnosis; — During an epidemic of plague we are warranted in looking 
on any case of fever with glandular hyperemia as that affection until proved 
to be something else. Pneumonic cases present difficulty. In any form 
the diagnosis is rendered positive by finding the specific bacilli in the sputum, 
blood, discharges or pus. The suspected matter is placed on a slide, dried, 
fixed, stained with aniline; any coccobacillus found with the poles stained 
is cultivated by Haff kine 's method in broth on which cocoanut oil is floated. 
From the under surface of the oil the plague bacillus hangs in stalactite 
growths; which, when disturbed, fall in snowflake masses to the bottom of 
the vessel. No other known bacillus does this (Manson) . 

Serum diagnosis does not appear to be of much practical importance. 
It is not demonstrable until late in the attack or during convalescence, 
and as it fails in the majority of cases this failure does not prove the absence 
of plague. A little serum from the patient is diluted with three volumes 
of normal salt solution, and placed in culture media with plague bacteria, 
when these agglutinate in small clumps. This phenomenon also occurs 
in the serum of animals that have been immunized with plague bacilli. 



no THE PLAGUE 

Ptognosis: — Bad signs are the seat of the bubo in the neck, the primary 
pneumonic form, the early appearance of the bacilli in the blood, or of 
severe constitutional symptoms with little glandular disease. The height 
of the fever is less significant. Sudden death from heart failure may occur 
in cases apparently doing well. Intense implication of the nervous system 
or of the gastrointestinal tract is unfavorable. Otherwise, prognostic 
indications may be drawn from the resisting powers of the patient, the 
period of the epidemic, his habits as to alcohol, etc., and his ability to com- 
mand good nursing and attendance. 

PwphylBxis: — Quarantine to be effective must extend over eight days 
from possible infection. Convalescents must be isolated from the com- 
munity for a month after recovery, since Kitasato has shown that the plague 
bacillus is found in their bodies for at least three weeks after the attack has 
subsided. Clothes and other articles possibly infected should be burnt. 
Infected ships should be fumigated and the rats thus killed, and burnt or 
sunk, before communicating with the land. The plague bacillus is killed 
by a few minutes' exposure to steam at ioo C, by half an hour to a temper- 
ature of 80 C, by one hour to 1 per cent carbolic solution, or three hours 
to fresh whitewash. Manson recommends for disinfectants steam, 1 to 
1000 mercuric cnloride in carbol-sulphuric acid, 1 per cent chloride of lime, 
and 5 per cent carbolic acid solution. He advises strict isolation of affected 
patients, houses and towns, destruction of infected material by fire, crema- 
tion of the dead, formation of segregation camps for suspected and exposed 
persons, killing and burning rats and mice, general sanitation, and special 
protection against diffusion by railways. In India the inspection of all 
dead proved advisable. Cases of walking plague are specially dangerous. 
He then acknowledges the inemcacy of quarantine. The enforcement of 
hygienic precautions, including the killing of rats and other vermin when a 
visit of plague is feared, is urged. . • ' 

Individual prophylaxis calls for avoidance of unnecessary exposure, 
scrupulous hygiene of the sick-room, protection of nurses from 
insects' attacks, and prevention of infection by sealing wounds and 
abrasions. 

Haffkine prepared a culture of plague bacilli, killing them by heat, and 
employed it by inoculation as a preventive, with considerable success; 
reducing the number of those attacked by about 4-5, and rendering the 
attacks milder. Others have obtained success less marked but still quite 
satisfactory. Lustig modified the serum by precipitating the nucleoproteids 
which could then be kept indefinitely in a dry state and administered in 
weighed doses. Similar cultures employed by successive inoculation to 
render rabbits and horses immune have furnished the serums of Yersin and 



THE PLAGUE in 

others. These have been employed as remedies with sufficient success to 
encourage further experiment in that direction. 

During the last epidemic in Sidney all quarantine restrictions were 
thrown aside, and patients treated on the principle of preventing the possi- 
bility of access of insects to the patient or the infection of epidemic lesions, 
while all material by which rats might become affected was carefully 
destroyed. This ' proved successful, and neither nurses nor physicians 
were attacked (Lydston). No pneumonic cases occurred; these probably 
require isolation. 

Tredtment: — Manson calls attention to the tendency to depression 
always present, contraindicating depressive measures. Much relief may 
be obtained from fever and headache in the early stages by applying ice 
bags to the head: warm sponging is safer than coal tar febrifuges. Lowson 
relieved vomiting with calomel followed by a saline. If this failed or if 
diarrhea began he advised 'ice pills' and an effervescing mixture containing 
morphine and hydrocyanic acid. When the pulse showed signs of failing 
he advised strychnine and ammonium carbonate rather than direct heart- 
tonics. He began with strychnine early and gave it as a routine remedy. 
In collapse stimulants — ammonia inhalations, ether injections — some- 
times succeeded. Morphine he found the best hypnotic. Hyoscine, chloral 
and bromide were of service; all in small doses. Urgent diarrhea he found 
best treated by intestinal antiseptics — salol gr. x every four hours. To the 
buboes he applied glycerin and belladonna; poulticing when red, incising 
when soft and dressing with iodoform, treated with iodine when indolent. 

Extirpation of the affected glands has been tried without success. 
Wilson urges the use of alcohol and in the next sentence acknowledges 
its inefficacy. Hydrotherapy also has failed. 

Get rid of the impression that veratrine is a 'depressant.' The restor- 
ation and maintenance of normal elimination is never depressing; and in 
all maladies which throw on the eliminant apparatus an enormous burden 
of debris that must be carried off, eliminants are the most powerful known 
means of raising the vital powers. By this means the heart may be more 
effectually sustained than by administering any quantity of cardiants. 
Nevertheless Lowson 's suggestion is wise, and it is well to forestall the 
occurrence of heart-failure in a malady where it appears so unexpectedly 
and overpoweringly, by beginning the use of strychnine in moderation 
quite early in the attack. The use of these remedies in small and oft- 
repeated doses enables the physician to accurately gauge the effects and 
avoid the dangers of over and under dosage. 

J. C. Thompson of Hong Kong finds phenol in great doses the most effec- 
tive remedy, giving 1 2 grains every 2 hours, 1 2 doses each day, well diluted. 



ii2 THE PLAGUE 

Saturation with calcium sulphide as a preventive and a means of 
destroying the parasites in the body, is a legitimate experiment and should 
receive the fullest trial. Especially is this measure indicated in those 
exposed to this infection but not yet displaying the symptoms. If there is 
the remotest chance that this remedy will destroy the first invading horde 
before they have multiplied sufficiently to inaugurate the sensible symptoms, 
the remedy being harmless if ineffective, it should not be neglected. 

Another remedy for whose use there is a sufficient basis of probability 
is pilocarpine, in full diaphoretic doses at the outset. The closely allied 
remedies, physostigmine, picrotoxin and muscarine, may in time be 
investigated in microbic infections. Especially in pulmonic forms should 
this group receive trial, the old treatment having so conspicuously failed 
here. Possibly the application of local germicides, like thymol iodide 
in an oily menstruum, to the bronchial mucosa, may prove beneficial. Less 
probable expedients have proved successful in our art. 

In regard to the fulminant cases, where the patient dies in a few hours, 
overwhelmed by the virulence of the attack, there is not a word as to treat- 
ment mentioned by any authority in our library. They unanimously 
give these cases up without an effort. We are not 'built that way;' if die 
we must, we prefer to ' die fighting. ' 

In the eruptive fevers we meet a closely analogous situation — the eruption 
does not appear but the patient dies in a few hours overwhelmed by the 
vehemence and suddenness of the onslaught. Sometimes we are enabled 
to stay the hand of death by arousing the patient's vital resistance; and 
for this purpose we administer camphor, capsicum or other local irritants 
that powerfully stimulate the gastric terminals of the afferent nerves. In 
the choleras, tropical dysenteries and pernicious malarias, this thera- 
peutic principle has proved applicable and has saved many lives. With 
all to gain and nothing to lose, it seems worthy of consideration here. 
Another remedy for this condition is atropine, full doses hypodermically. 
With this glonoin and strychnine mav be combined, making an efficacious 
remedy for the condition described. 

For collapse there is one remedy not mentioned yet — the very hot, 
stimulant bath. Anyone who has witnessed recovery from cholera collapse 
when the patient is placed in a hot mustard bath and hotter water added 
till reaction occurs, will comprehend the value of this suggestion. 

Resume. 
Preliminary : Calomel to arouse liver 

Saline to empty bowels 

Sulphocarbolates to deodorize stools 
Dominant: Calcium sulphide for infection 



ERYSIPELAS 113 

Variants: Aconitine ■ to allay fever 

Digitalin to sustain heart 
Strychnine arsenate to incite vitality 

Veratrine to open elimination 

Nuclein to reinforce phagocytes 

Pilocarpine to incite leucocytosis 

Capiscin to arouse vital resistance 

Atropine to arouse vital resistance 

Glonoin to hasten action of other remedies 

ERYSIPELAS 

Erysipelas is a contagious malady, endemic, sometimes epidemic, 
caused by the streptococcus erysipelatus or pyogenes. It is somewhat more 
frequent in the spring. It haunts unhygienic hospitals and other institu- 
tions. It is inoculable and portable by an unaffected person. The 
liability to it is universal but to permit the entrance of the cause it requires 
a lesion of the surface of the body, though this may be exceedingly slight. 
Alcoholism, nephritis and debilitated conditions in general are predisposing 
causes; and one attack seems to render the victim more liable to others. 
The symptoms are due to the toxins produced by the coccus, and a protective 
serum has been produced, Marmorek's, by intensive inoculations of the 
horse. It is a bacterial and not an antitoxic serum. Its value has not been 
fully demonstrated. There are a number of streptococci which can not 
well be distinguished, and the serum from each protects only against that 
one; and erysipelas may be caused by more than one of these organisms. 

Erysipelas is a dermatitis, with edema, the cocci occupying the lymph 
spaces, abounding in the spreading edges. Beyond the margin of redness 
they are found in the lymphatic vessels, where they wage deadly war against 
the defending leucocytes, according to Metschnikoff. In severe cases there 
is suppuration. It may pass along the planes of fascia to the deeper 
structures. A sailor under the writer's care had a boil on the forehead. 
He visited a friend suffering with erysipelas, this affected the boil which 
had opened up the deeper structures of the scalp, the infection traveled 
through the orbit to the brain, and the man died of meningitis. 

Erysipelas may cause septic infarcts, pyemia, endocarditis, pleurisy 
or pericarditis, pneumonia or acute nephritis. 

The incubation is from three to seven days, perhaps less. The invasion 
may be marked by chilliness with acute fever; the skin lesion is surrounded 
by a rosy zone which widens rapidly, spreading by the edges. It is most 
frequent on the face, beginning at the mucocutaneous margin, most often 
at the outer corner of the eye. The skin is swollen and tense, red, hot, 



ii4 ERYSIPELAS 

sometimes the epidermis raised in blisters, large or small. The margin 
is well-defined and raised. The eyes swell shut. The fever rises to 102 
or 104 , and as the scalp is involved delirium is common. The glands 
swell but may be hidden by the general edema. Leucocytosis is present. 
Leucin and tyrosin have been found in the urine. In weakly and cachectic 
persons delirium and prostration supervene quickly; or the malady may be 
characterized by pronounced asthenia from the first. The eruption is then 
pale, pulse weak and fever slight. The tongue soon becomes dry and de- 
pressing toxemia threatens death. The eruption may extend to the mucous 
membranes and edema of the larynx become a dangerous complication. 

Usually the disease does not progress beyond the head, but sometimes 
it passes to the chest and may irregularly traverse the whole surface of 
the patient. When the entire head is affected the disfigurement is great. 
Abscesses are common about the face, and sometimes the deeper planes 
of connective melt away and large collections of infective pus form. 

Albuminuria is usual, especially in elderly subjects. Malaria may 
coexist. During convalescence Da Costa noticed febrile recrudescences. 

Diagnosis is made by the onset, rapid rise of fever, the regularly spread- 
ing rosy flush, and fading which commences four days after it has reached 
any location. 

The prognosis is good, except for the aged and cachectic, drunkards, 
and when the meninges are affected. Attacking newborn infants at the 
navel it is fatal. 

Twenty-five years ago the writer first used jaborandi for erysipelas. 
The patient was a husky beer-drinking woman, whose face was nearly 
covered with the flush. She was given fluid extract of jaborandi, m. v. 
every hour till sweating began. By this time the erysipelas began to recede 
from its edges. The remedy was then suspended, and next day the 
eruption had begun to regain its lost ground. For some days this alternation 
was pursued, until it was evident that the remedy had perfect control over 
the disease, and then it was given until the flush had completely disappeared, 
and the woman was well. The next case was similar; a physician preceding 
the writer had placed the patient on large doses of tincture of iron, at each 
of which she became wildly delirious. Jaborandi exerted the same complete 
control over the erysipelas and she was soon well. For years the same 
result followed in every case, the only difference being in the substitution 
of pilocarpine for jaborandi, after the failure of the latter in one case, owing 
to lack of pilocarpine and an over-plenty of jaborine. 

One day a case presented in which pilocarpine failed to cause sweating 
cr salivation, or to influence the erysipelas beneficially; but each dose was 
followed by an increase in the already marked depression under which the 



ERYSIPELAS 115 

patient labored. In this case the asthenic form presented, with pale erup- 
tion, slight if any fever, weak pulse and general prostration. The treatment 
was changed to tincture of the chloride of iron, thirty drops every four hours, 
and nourishment crowded; improvement set in at once. 

This is the history of erysipelas in the writer's practice for twenty-five 
years since. Every sthenic case recovered under pilocarpine; every 
asthenic case under iron. No deaths. 

No local treatment — why should one use it ? 

Le Grix describes a case of facial erysipelas, an English lady, aged 25 
years. The malady developed upon a coryza, at the margin of the interior 
nares, and spread over the face. She was first seen three days after the 
beginning of the attack. The malady had extended to the neck, where 
many glands were enlarged and painful; the lachrymal sacs suppurating, 
the eyes closed. She vomited spontaneously, had a most violent headache, 
with nightmares all the preceding night; constipated, urine scanty but not 
albuminous, tongue heavily coated, throat red, nostrils dry, pulse 120, 
temperature 40.5 C. 

She was placed upon aconitine, veratrine and calcium sulphide, two 
granules each, with one of strychnine arsenate, given together every half 
hour. After the sixth dose the fever had fallen to 38.5 C. She passed a 
good night. Next morning the temperature was 3 7 C. The same remedies 
were given every three hours, adding one granule of digitalin three times 
a day. Improvement was evident; the head was clear, sensibility less, 
the headache had disappeared. A saline laxative was given each morning. 
The menses appeared prematurely without pain. 

On the second morning of treatment the temperature was 36.8 C. but 
rose in the evening reaching 39.8 at 6 p. m. This was followed, however, 
by a good night. In the morning the temperature was 36.8 C, the face 
desquamating but the eyelids had swelled again. The granules were given 
every two hours and the temperature rested at 37 degrees C. from noon till 
midnight. The eruption subsided rapidly, the hairy scalp remaining tender 
with some edema. The urine became more abundant and clearer. She 
was dismissed as cured on the fifth day of the treatment. 

The reporter remarks that the evolution of a facial erysipelas so extensive, 
intense and acute, is remarkable for the rapid jugulation of the fever, treated 
at the end of the second day from its appearance, disappearing totally in 
twelve hours, reappearing twelve hours later and finally vanquished six 
hours after the second attack. Jugulation followed the first six doses as 
given above. This case was remarkable also by the appearance at each 
menstrual epoch of facial congestion. 



n6 DIPHTHERIA 

DIPHTHERIA 

The term diphtheria had better be limited to cases presenting the 
Klebs-Loeffler bacillus, in the interest of scientific accuracy. Some of these 
are simple sore throats, but they may take on the features of malignancy 
whenever conditions favor this development. There are other cases 
presenting the clinical features of malignant diphtheria in which this bacillus 
is not found, but that is not positive proof that it is not there nor that they 
may not become affected with this organism subsequently. 

Clinically, it is safe to look on every sore-throat as possibly diphtheritic 
now, or at any time in the near future, and to take all known precautions 
against its becoming so. 

Diphtheria is a disease characterized by pseudomembranous deposits 
on diseased mucous membranes and upon sores or mounds, with toxemia 
from absorbed poisons therefrom. Diphtheria is always to be found in our 
cities and becomes epidemic at times. It also prevails in isolated country 
places. It is contagious but much less so than scarlatina. The sources 
of contagion are not easily traced. It clings to infected houses and drains, 
attacking families that successively inhabit unhygienic dwellings. The 
writer knew one such house, where the cess-pool filled with water from a 
spring and overflowed under the kitchen, where the floor was constantly 
saturated with sewage. All the children died of diphtheria; and every 
family that occupied that house for ten years lost its children in this way. 

In Germantown, Pa., the rivulets forming the head of Wingohocking. 
Creek drained several cess-pools from houses in which diphtheria existed 
The stream was covered over part of its course with a sewer, and along that 
portion there was no such disease; but when trie cover ended and the creek 
formed an open sewer, in houses about the mouth of the culvert residents 
were affected with diphtheria. 

In the city while scarlatina and smallpox could be traced with ease, 
it was impossible to locate the source of diphtheritic infection in most 
instances. In one case infection seemed to have been carried to an isolated 
farm-house in a barrel of apples from an infected place. It was reported that 
the bacilli were detected in decayed spots in the fruit. 

The infection may be communicated from the membranes and discharges 
of patients, from the secretions of convalescents, or be carried by healthy 
persons in contact with patients. The viability of the germs seems to have 
no limit, and they have been detected in the throats of patients for a year 
after an attack. Many physicians and nurses have fallen victims to bits 
of infected material coughed into their mucous tracts, or taken in while 
clearing tracheotomy tubes. The bacilli have been found in dust of infected 



DIPHTHERIA 117 

rooms, in the feltlike growth of pipes leading from stationary basins to 
sewers, in the hair of nurses, in milk and cheese. It is generally believed 
that cats are affected and spread the disease, but Osier denies this. 

Some persons are immune at some times. Any age is liable but most 
deaths occur between two and five years. Adults are liable. The disease 
prevails most in winter. Any affection of the pharyngeal mucosa opens 
the door for diphtheria. The writer has seen the deposit in a suppurating 
ear. Epidemics vary in malignancy, and fatal attacks may come from 
inconsequent and non-membranous sore-throats. In the West Indies 
there prevails among natives a harmless affection from which northern 
visitors contract fatal diphtheria. 

The specific bacilli are found in the membranous deposits and do not 
penetrate the tissues in large numbers. They may reach the blood and be 
widely disseminated by it. This may be the only organism found in the 
attendant bronchopneumonia. It has been detected in endocardial ulcers. 
It is non-motile, from 2.5 to 3 micromillimeters in length and 0.5 to 0.8 in 
width, a straight or bent rod, with rounded ends, sometimes swollen or 
branching. Growth in cultures ceases at 20 C. It is very tenacious of life. 
Its virulence varies widely. It has been detected in ordinary catarrhal 
pharyngitis and laryngitis, in follicular tonsillitis and in throats pre- 
senting no evidence of disease. The antrum has been found to 
be infected. 

Roux and Yersin isolated a toxin which is the direct cause of death 
by diphtheria but does not produce false membrane. Attenuated cultures 
of the bacilli, or dilutions of the toxin, injected into a susceptible animal 
produce a febrile reaction, that grows less with each repetition until it 
ceases and the animal is immune. 

The most important other organism found with the diphtheria bacillus 
is the streptococcus pyogenes, which may infect the system. Others are the 
micrococcus lanceolatus, bacillus coli communis, staphylococcus aureus and 
albus, bacillus xerosis, etc. Non-virulent bacilli resembling that of 
diphtheria have been found in many diseases. In membranous affections 
where Loeffler's bacillus is not found, the streptococcus pyogenes is usually 
present; also in diphtheritic bronchopneumonia. These occur in a varying 
proportion of cases in an epidemic of diphtheria, also in scarlatinas, measles, 
whooping-cough and typhoid fever. These cases are less dangerous than 
true diphtheria, except in the fevers, when general infection is not uncommon. 
There may be a simple catarrh or a creamy pultaceouS exudate; or follicular 
tonsillitis, the deposit spreading over the pharynx and sloughing ensuing. 
They are slightly if at all contagious. The most extensive paralysis may 
follow. 



n8 DIPHTHERIA 

Anatomy: — In 127 fatal cases the membrane appeared on the larynx 
in 75, trachea 66, tonsils 65, epiglottis 60, pharynx 51, nasal mucosa 43, 
bronchi 42, soft palate and uvula 13, esophagus 12, tongue 9, 
stomach 5, vagina 2, duodenum, vulva, external ear and conjunctiva 
1 each (Osier). 

The accessory sinuses were frequently involved. The membrane dips 
down into the mucous tissues and so interferes with their blood-supply 
that necrosis or gangrene results. The membrane varies from white to 
gray, greenish, brown or black, being most frequently ashy. Ulceration 
may open the carotid artery. Any of the nasal passages or sinuses may be 
blocked up with exudation and necrosed tissues. The affection may spread 
along the nasal mucosa to the sphenoid, ethmoid or frontal cells, by the 
eustachian tube to the ear, or the nasal duct to the eyes, to the antrum, 
malar bone, larynx and trachea, rarely to the esophagus and stomach, 
more frequently to the mouth, causing ulcers at the corners. The anterior 
nares may be eroded. Where the mucous membrane is rich and succulent 
the disease penetrates deeply, the destruction of tissue is great, and the 
neighboring lymphatics are involved. If the membrane is thin and scantily 
supplied with blood and the lymphatic connections few, the membrane is 
"croupous," and the lymphatic involvement slight. The membrane may 
be tenacious or pulpy. The first action of the bacilli is local; the primary 
lesion necrosis of the epithelium; the organisms grow in dead, not in living 
tissues. Active proliferation of cell nuclei precedes necrosis, and fibrinous 
exudate pours out underneath, forming fibrin in contact with necrotic 
epithelium. Part forms a network around the exudation cells and dead 
epithelium, part combines with the hyaline degenerated cells. With or 
without it a hyaline membrane may be formed, the fibrin probably dipping 
into the tissues. The cells which it surrounds disappear. The membrane 
disintegrates from the surface inwards, or is pushed off by exudation. It 
never begins on a sound epithelium but extends over it. The connective 
and vessels undergo hyaline fibrinous degeneration. Necrosis may extend 
deeply but there is little tendency to abscess. The degeneration of the 
mucous glands is almost specific. 

In the heart we find fatty degeneration, primary and secondary myo- 
carditis, rarely peri and endocarditis, the Loeffler bacilli in the vegeta- 
tions. Bronchopneumonia causes as many deaths as the throat disease. 
Pneumococcus pneumonia is rare, diphtheria bacilli and streptococci 
frequently infesting the lung. The kidneys are affected by the toxins, 
varying from degeneration to intense nephritis. The liver and spleen 
are degenerated as in other acute infections. General infection occurs 
in grave cases, with the diphtheria bacillus or streptococcus, or both. 



DIPHTHERIA 119 

Symptoms: — The incubation lasts from a day to a week. The onset 
may be marked by chilliness, fever, aching head, back and legs, the tem- 
perature reaching 102 to 104 F. Convulsions may occur in children. 
Rarely do patients mention the throat unless asked of it; the usual com- 
plaint is of headache. There may be no complaint; the writer has called 
a child in from its play four hours before its death. Never omit to examine 
the children's throats when diphtheria is about, and the mother apologizes 
for troubling you, but fears "the child may not be just right." You will 
find the tonsils red, a little stiff, and a thin pellicle of membrane, ash- 
tinted, closely adherent. The child does not say there is soreness on 
swallowing, but may if asked. The membrane thickens and spreads 
by the edges, sometimes with rapidity. The glands at the angle of the 
lower jaw are swollen and tender. Detach the membrane and a raw 
surface is left, with bleeding points. The deposit is soon reproduced. 
There may be no fever or acceleration of the pulse. This may comprise 
the whole attack, and within a week the membrane is detached and the 
patient convalescent. In fact, many cases run their course without excit- 
ing suspicion of their true nature. 

According to Koplik there are cases of simple catarrh with croupy 
cough, others with a pultaceous exudate on the tonsils, some with a punc- 
tate membrane, isolated; and some with a typical follicular tonsillitis 
These may run a mild course or take on malignancy, or extend rapidly. 
Heubner describes a latent form, in weakly strumous subjects, with fever, 
nasopharyngeal catarrh and digestive trouble, with nothing indicating 
diphtheria till laryngeal symptoms develop; or it may be found only, 
at the autopsy. 

Even with severe implication there may be slight systemic infection, 
Or, there is great prostration, high fever, pulse fast and weak, hebetude 
rather than delirium and the patient dies soon of toxemia. This has 
never occurred in the writer's practice except when the nose was affected. 
The temperature may be subnormal; in fact fever is not a feature of 
diphtheria, per se. But when extensive tracts are involved and toxic 
products are being absorbed, the discharges fetid, there may be fever 
above 104 F., the end of the nose, fingers and toes cold, the forehead 
burning hot, pupils contracted, mind clouded or comatose, face pale, 
the glands swollen, both lymphatic and salivary. Suppuration or gan- 
grene may set in, but never has the writer seen such extensive destruction 
as in the angina of scarlatina. Escherich accounts for the divergence 
by assuming that there may be a high local susceptibility to the malady 
with a slight general impressibility, or vice versa. Leucocytosis is usually 
present in all grades of the disease. 



120 DIPHTHERIA 

Sometimes, when the affection on the tonsils has progressed a day 
or more, there appears a slight coryzal discharge from one or both nos- 
trils. Let alone, this soon becomes turbid and irritating, excoriating the 
nostril and causing intolerable burning. The discharge becomes ichorous 
and frightfully offensive, and blood appears, which will go on to fatal 
epistaxis if not successfully treated. The affection then spreads to the 
mouth, causing ulceration of the gums and at the corners of the mouth 
as well as the inside of the cheeks; to the ears, causing earache, deafness 
and otitis media with penetration of the drum and the appearance of the 
exudation in the external meatus; along the nasal duct, with ulceration 
at the inner can thus of one or both eyes; or to the larynx, causing hoarse- 
ness and aphonia, with the symptoms of membranous croup in 
children. 

The writer does not believe all cases of membranous croup are lar- 
yngeal diphtheria. The Klebs-Loeffler bacillus was found by Park 
and Bebeerin in only 229 out of 286 cases. The reaction of the two mala- 
dies to treatment is different. The symptoms are similar — the croupy 
cough, hoarseness, aphonia, worse at night, with impeded inspiration, 
and the boat-shaped depression of the abdomen calling for tracheotomy 
or intubation. 

Diphtheria may begin in the conjunctiva, causing catarrhal or mem- 
branous disease; or in the ear if there is suppuration there. It may 
attack any wound, ulcer or other lesion of the skin if not protected by 
impervious coverings. The course is similar to that on the mucosa. 
Paralysis may follow either. Diphtheria of the genitals is rare. 

Dangerous hemorrhages may occur from the nose or throat. Ery- 
thema, urticaria and purpura occur sometimes. Catarrhal pneumonia 
is present in most fatal cases. Jaundice is catarrhal and not serious. 
Albuminuria is present in all serious cases. If abundant with blood 
casts, it indicates alarming nephritis. Suppression may follow, rarely 
with dropsy, coma and convulsions. Any organ may be infected by the 
transmission of septic matter through the blood. Paralysis is the chief 
sequel. It may follow mild forms. It is more frequent in adults. It 
usually affects the muscles of deglutition, but the writer has seen it in 
about all the rest of the muscular system except this. It is due to septic 
neuritis, multiple or confined to a part. Many die. The paralysis may 
be permanent. 

One death in five is due to heart-failure, usually in the second week. 
Slowness of the pulse is a serious symptom. The patient is pallid, the 
pulse weak and slow or fast, the extremities cold, and collapse supervenes 
with death in a few hours. This may occur during convalescence, after 



DIPHTHERIA 121 

exertion. There may be no physical signs other than slight increase in 
the cardiac dullness and a gallop rhythm or embryocardia, indicating 
dilatation (Osier). 

Diagnosis: — The only real proof is the demonstration of the presence 
of the specific bacillus. Place the child in a good light, properly held; 
depress the tongue and rub a cotton swab gently but freely against any 
visible exudate; if not visible avoid the tongue and pass the swab far 
back and rub freely against the pharynx and tonsils; without laying it 
down withdraw the cotton plug from the culture tube, insert the swab 
and rub that portion that has touched the exudate gently but thoroughly 
all over the surface of the blood serum. Do not push the swab into the 
serum or break its surface. Replace the swab in its own tube, plug both 
tubes, put them in the box, and return at once to the station. The above 
are the directions of the New York Health Department. The tubes are 
kept at 39 C. in an incubator for twelve hours, and then examined. Lar- 
yngeal cases may not show the bacilli at the earlier examinations. It is 
safe in all possibly diphtheritic cases to look upon them as such until 
proved innocent, and take all precautions as to treatment and isolation. 

Streptococcus cases are usually milder, less infectious, but bad enough 
to make the above apply to them also. 

In the Boston City Hospital the mortality was 46 per cent; since the 
introduction of antitoxin it has fallen to 12 per cent. The prognosis is 
so largely influenced by the treatment that it is difficult to estimate with- 
out taking that into consideration. Bad hygienic surroundings are often 
fatal. Extension to the nose or any of the passages communicating with 
the pharynx is the signal for a fight for the patient's life; extension to the 
larynx is generally an indication for the undertaker. Marked nervous 
implication, hebetude, heat of head and cold extremities, great depression 
and contracted pupils, signify sapremia, and while serious are amenable 
to treatment. Scanty or suppressed urine with acute nephritis is ominous. 
The disease is essentially covert, insidious, and the mildest case must be 
watched carefully, even through the convalescent period. The paretic 
sequels are often, but not always, amenable to treatment. 

Prophylaxis: — The patient should be isolated, the clothing disin- 
fected, the sick child kept from school until the infective period has passed. 
But this means until the bacilli have disappeared from the throat, and 
only by repeated bactieriologic examinations can this be determined. 
Many of the dangers are obviated if the patient is removed to a special 
hospital for such cases, which is one of the most difficult problems in city 
hygiene. Few mothers willingly part with their children with an appar- 
ently slight ailment to send them to a hospital among malignant cases. 



122 DIPHTHERIA 

In case of death, the body should be invested in antiseptic wrappings, 
hermetically sealed, and buried — or, infinitely better, cremated — at once, 
with no funeral permitted. 

A great advantage gained by the use of local germicides is the lessen- 
ing of infective possibilities. Such remedies should be applied to the 
throats of every member of the family several times a day. 

Treatment; — The history of diphtheria is a record of the stubborn 
determination of the medical profession to treat it as a constitutional 
affection, in spite of the most glaring proofs of the superior efficacy of 
local applications. An instance of this occurred many years ago in Paris, 
where the regular faculty was losing its cases, and an old woman in an 
alley was obtaining such success that a committee was sent to ascertain 
the reasons. It was found that her main reliance was on local applica- 
tions of silver nitrate. But there are better local remedies than this. 

For over half a century chlorine has occupied a high place in the esti- 
mation of those who have tried it. The original formula appeared in 
Greenough's work on Diphtheria, as follows: Potassium chlorate, pow- 
dered, one dram; put in a four-ounce vial and add a dram of strong hydro- 
chloric acid and two drams of tincture of chloride of iron; when the fumes 
of chlorine rise in the vial add water to make four ounces. The dose of 
this is a dram, undiluted and with no water after it, to be repeated every 
one to four hours, for any age above a year. As it is quite a strong acid 
solution it is well to give water before each dose, to dilute it in the stomach. 
In a few cases where it erodes- the mucous membrane, and for children 
under a year, it may be applied on a swab instead; but when it can be 
swallowed it reaches the affected parts better and has a valuable effect 
as a general stimulant besides. It is rare for any child to refuse it; the 
burning from the disease in advanced stages is so great that the writer 
has seen a two-year-old boy rise on his elbow and beg for the dose which 
momentarily stops this distress. 

But this is not enough; it is as frequent as the remedy should be applied, 
but not enough to stop the progress of the diphtheritic process. The 
bacillus never sleeps; the exudate spreads with frightful rapidity; one can 
almost see it grow before his eyes. And when we try to put out a fire 
we must not stop a moment until it is all out, or it will relight and our 
labor go for nothing. Wash out the affected area with peroxide of hydro- 
gen solution, the full strength of the 15-volume, and repeat this every 
quarter-hour while the patient is awake and every half-hour while asleep. 
There is really no objection to waking the child; it is but a minute and 
the is asleep again, so that his rest is not disturbed. But let a mistaken 
enderness leave him a few hours without the medicine and the disease 



DIPHTHERIA 123 

may have penetrated beyond the reach of local remedies. And it must not 
be forgotten that one thorough application is worth more than a dozen par- 
tial or slovenly ones. Again the simile of extinguishing a fire is applicable. 

The local remedies must be strong enough and applied often enough, 
to accomplish their purpose, or they will fail. It is the lack of apprecia- 
tion of the truths herein set forth, that leads physicians to undervalue 
the importance and efficacy of local antisepsis. 

If the child resists the applications and it is necessary to use force, 
let the nurse take it in her lap with the back to you; then rest the back 
of its head in your lap, and hold the nose shut for a moment until it opens 
its mouth; then slip a large cork in to hold the mouth open, and the appli- 
cation may be thoroughly made in a moment. It is rarely necessary to 
repeat this procedure; the relief following will make the child willing to 
have the remedy applied. 

Doubtless other applications are as useful as those recommended; 
we speak of those we have learned to trust after a third of a century's 
use. Osier speaks highly of LoefBer's solution: Menthol, 10 drams, 
dissolved in toluol to 36 cc, liq. ferri sesquichlorati 4 cc, absolute alcohol 
60 cc. Lactic acid dissolves the membrane without affecting healthy 
tissues much. Salicylic acid in saturated solution is especially effective 
as a lotion in streptococcus cases. 

When the first traces of coryza show invasion of the nasal tract, syringe 
with silver nitrate, one per cent, or five grains to the ounce of water; 
repeat every four hours as long as the discharge appears. In the intervals 
use peroxide freely every quarter and half-hour as above described. If 
there is a trace of blood from the nose, make a solution of chromic acid, 
a grain to the ounce, and syringe with it the affected nostril. If neces- 
sary increase the strength until it stops the bleeding. This has never 
failed in the writer's hands. Loeffler's solution diluted as little as possible 
is also effective against the coryza. If the larynx is affected there is little 
hope, unless from internal treatment. The writer has never seen benefit 
derived from steaming. Ice to the neck and ice or ice-cream by the 
mouth, are always useful — a fact noted long before the inhibitant action 
of cold on these bacilli had been demonstrated. When in the laryngeal 
form the abdomen is retracted on inspiration, intubation should be at 
once performed, before suction has produced pulmonary edema. 

The food should consist of the richest nutriment the child can digest, 
in small doses, taken every two hours. Predigested foods, ice-cream, 
cafe an lait, scraped raw beef and oysters, concentrated beef powders, 
bovinine, sanguiferrin, clam broth, turtle soup, egg-white in ice-water, 
and fresh fruit juices, are best. 



124 DIPHTHERIA 

No internal remedy has won the repute of calcium sulphide. When 
this was introduced to regular medicine by Ringer it was advised in doses 
of gr. i-io every hour. We now know that it is safe and effective in 
twenty times this dose. A physician in Salonica, using little doses, had 
notable success with this agent and published his success. Just then 
he met a series of malignant cases, and the sulphide failed; whereupon 
he hastened to retract his encomiums. Had he increased his doses, at 
the same time attending to the unhygienic conditions that induced malig- 
nancy, his success would have been equal to his first experiences. 

Give calcium sulphide to a child of two years, in doses of a grain every 
hour, until saturation is denoted by the odor of sulphureted hydrogen 
on the breath and skin, or until nausea occurs. The beneficial effects 
will be unmistakable. Continue the drug in smaller doses to keep up the 
effect until the membrane has come off. 

So necessary is it to sustain the heart, and so insidious is the debili- 
tating action of the toxin, that it is wise to give moderate doses of strych- 
nine from the start; and to increase them when there is any sign of weaken- 
ing circulation. 

THE TOXIC SYMPTOMS ARE DUE TO SAPREMIA, NOT 
SEPTICEMIA. This is proved by the effects of cleaning away the 
morbific matter that is being absorbed. Take a child whose nasal tract 
is infected and packed with membrane and necrotic tissues, whose horrible 
stench drives everyone from the room. The child lies with eyes half 
shut, pupils contracted, stupefied, the nose and extremities cold, the 
forehead burning hot, pulse fast and thready, temperature high, or sub- 
normal. Wash out the affected cavities with peroxide, do it thoroughly — 
and consciousness has returned, the eyes are normal, pulse strong, tem- 
perature equalized, and the child is sitting up and asking for food and 
her toys. Could this occur if the toxins had not been absorbed from the 
tract just cleaned? 

A typical case: A child two years old, red hair and the delicate fragile 
skin that accompanies it; living in a dark unventilated court in a great city; 
family poor, father a drunkard, big family in a three-room house, hygienic 
conditions very bad. Two accomplished physicians connected with a 
great medical university had been in attendance and had given up the case 
as hopeless — with which prognosis the writer fully concurred. The disease 
had penetrated to the nose and had infected the whole tract, the drums 
of both ears had given way and were discharging, at the inner corner of 
each eye ulceration had begun, the upper lip and the corners of the mouth 
were ulcerated, and from all this extensive territory poured a flood of that 
ichorous matter whose terrible odor we have already mentioned more than 



DIPHTHERIA 125 

once. This was before the day of antitoxin, and past the time-limit of its 
efficacy at any rate. There was little to hope, the case was desperate — 
but the prospect for a battle royal — for such a fight as arouses every drop of 
Irish blood in one's veins. So — off with the coat and up with the sleeves — 
this was a chance for a doctor who loved his profession for its opportunities 
for just such work. The system of treatment above detailed was put in 
operation, with tincture of iron as the main standby internally — no sulphide 
yet; the chlorine mixture was given in half-dram doses every two hours, 
and peroxide faithfully used as above. The father kept sober, and f un- 
comprehending the conditions, carried out the plan as thoroughly as any 
trained nurse could have done. Six quarts of peroxide solution were used 
in six days, at the end of which the child was out of danger. No erosion 
of the membranes followed either the strong chlorine solution or the 
peroxide, which was applied in the full 15-volume strength. 

One looks back on such triumphs with a satisfaction greater than that 
following the receipt of a thousand-dollar fee for performing an unnecessary 
operation on a trusting patient. 

We come now to antitoxin: There is no reasonable doubt now as to 
its efficacy; so much so that no physician is justified in permitting a patient 
to go without it. When by repeated inoculations an animal has been 
rendered immune, the serum from that animal's blood, will when introduced 
into a human being's blood, render that person likewise immune against 
infection with diphtheria, and cure it if not too far gone. Antitoxin is 
measured by units, one being the quantity necessary to neutralize in a 
standard guinea-pig 100 times the minimum fatal dose of standard toxin. 
The dose to be administered is what will produce the desired effect; which 
may be 1,000 units or 50,000. We cannot know just how much toxin 
is being produced in any case, and what is produced must be neutralized 
be it much or little. When 'dose enough' has been given the membrane 
will shrivel, the nasal discharge lessen, the fetor improve, and the general 
state change for the better. If seen early the quantity required will be 
from 4,000 to 6,000 units. The objectionable features are hardly worth 
mention — urticaria and arthralgia, sometimes an abscess. 

To protect from the malady persons not yet affected, injections of 300 
units suffice for a child, 500 for an adult; to be repeated every few days 
while exposed to the disease. 

By the use of antitoxin the mortality from diphtheria has been reduced 
from 38.4 per cent to 9.8 per cent. 

The curative effects are greater the earlier in the attack antitoxin is 
administered. Larger doses are required for each successive day till the 
4th, after which there is little benefit to be hoped, unless experience shall 



126 RHEUMATISM 

show results from larger doses than are commonly given. But even here 
the antiseptic treatment described will save most of the cases. Without in 
any way decrying the use of antitoxin — which no reasonable man can do — 
we need not forget everything else we ever knew. 

Post-diphtheritic paralysis calls for the treatment of such affections 
from ordinary causes — massage, electricity and strvchnine, with passive 
motion — and patience. 

Verette says that some very wise, distinguished and especially "official, " 
confreres wish to force upon us the use of antitoxin even with patients who 
are not ill, making it a case of conscience. He finds, however, that the 
serum is by no means a panacea, and that there are other remedies as good 
if not better for the cure of diphtheria; and since it has not yet been demon- 
strated that by itself alone the serum suffices to cure a confirmed croup, he 
prefers to maintain his independent opinions, and to employ a medication 
which before the discovery of the serum had proved effective, without having 
had the numerous failures and grave inconveniences met in the employ 
of antitoxin. What imports magister dixit? The master is too often 
mistaken, and is too often led into error, for us to accept without protest 
what he wishes to impose upon us. Independence is the brighest gem of the 
medical crown — perhaps the only one. 

A child four years old, with typical diphtheria of the tonsils. The 
treatment consisted in the administration of calcium sulphide, with local 
applications of resorcin, iron and cocaine. Improvement was manifested 
on the following day, and in four days the child was well. Two younger 
children in the family were saturated with sulphide and escaped contagion. 

Robert Tissot, after discussing the relative merits of calcium sulphide 
and antitoxin, reaches the following conclusions: 

Antitoxin presents dangers and may by itself cause death. By its use 
the malady of diphtheria is reduced to 9 per cent. 

Calcium sulphide given, dosimetrically is perfectly inoffensive. By 
its use the mortality in diphtheria is reduced to 7 or 8 per cent. 

Guinon and Netter report improved results from the use of collargol, 
bv inunction and intravenously. 

RHEUMATISM 

Rheumatism is a disease of the fibrous structures around the joints, 
affecting them successively, attended by fever, and acidity of the urine 
and perspiration. It is now believed to be infectious but not contagious, 
and to depend on some unknown microorganism. It is thought to be a 
disease of damp climates, yet it prevails to a remarkable extent in South 



RHEUMATISM 127 

Africa, where the air is phenomenally dry. The constant blowing of the 
trade winds there, abstracting heat and moisture from the body, may account 
for this. Attacks are more common in fall and winter. Rheumatism is 
infrequent in childhood, becoming more common in early adult life, less 
so after the 40th year. Females are more liable up to the 15th year; males 
after this age. The prevalent belief in its heredity has been questioned, 
and it is now claimed that house infection accounts for the occurrence of 
several cases in a family. It occurs in drivers, sailors and others who are 
exposed to cold, damp winds. Such exposure often induces an acute attack. 
Each attack increases the liability to others. 

The arguments in favor of the infectious nature of rheumatism are, 
its occurrence in epidemics followed by mild outbreaks, as occurs with 
other undoubtedly infectious diseases; the similarity of the symptoms and 
course to the latter; the presence of microorganisms in the blood during 
the attack, one of which injected into rabbits produced cardiac inflam- 
mations. This view is strengthened by the frequent concurrence of 
rheumatism with tonsillitis and other affections of the pharynx believed to 
be of microbic origin. Since his attention was directed to this point the 
writer has not seen a case of rheumatism which was not preceded by such 
a throat affection. It may be simply a redness, with some swelling of the 
glands, or a suppurative quinsy. 

t The older view attributed rheumatism to the production of lactic acid 
in the alimentary canal. The writer had an attack develop in a patient 
who was taking strontium lactate for diabetes. Richardson produced 
rheumatism by giving this acid and injecting it. This view may be har- 
monized with the preceding if we attribute the acid to the action of tmi- 
crobes in the stomach or bowels. 

Rheumatism has also been attributed to nervous derangement, eiher 
due to direct action of cold or to the disturbance of metabolism producied 
by it, one result of which may be the generation of lactic acid. 

Affected joints show hyperemia of the fibrous structures and synoval 
membranes, the fluid turbid, albuminous and containing leucocytes. Pus 
is almost unknown. The disease is rarely fatal except through cardiac or 
pulmonary complications. The blood contains an excess of fibrin. In 
secondary inflammations the presence of pus shows complicating infections. 

After the throat affection the acute attack sets in with a rigor, chilliness 
and fever; one of the joints also begins to ache, becomes tender and swells. 
Fever rises to 102 — 4 ; pulse above 100; tongue moist and white; anorexia, 
thirst; acid indigestion, urine and perspiration; urine scanty and sweating 
free; sudamina and milia plentiful; no mental involvement. As the 
inflammation appears in a new joint the last one attacked improves. The 



128 RHEUMATISM 

large joints are most frequently attacked at first, but all in the body may be 
involved successively, even those of the vertebral column and the lower jaw. 
Most of the arthritic swelling is due to the extra -articular infiltration. 
Motion of the infected joints is impossible, the weight of the bed-clothes 
may be intolerable. In spite of the suffering, interference with digestion 
and free sweating, the prostration is remarkably moderate. The fever 
is irregular, rising when a new joint is involved, remitting or intermitting 
irregularly. It falls by lysis, except after profuse sweats. Leucocytosis 
is marked. Anemia soon supervenes. Albuminuria is common. The 
saliva may be acid and contain an excess of sulphocyanides. Murmurs 
may be heard in the heart during the pyrexia. 

Rheumatism is more acute and painful in the young. Subacute forms 
are more frequent in older subjects, but there is as much danger of cardiac 
involvement as in the severe forms — some claim more. 

The complications are hyperpyrexia, sometimes with delirium, more 
common in first attacks, fever reaching 108 , with the usual symptoms of 
this condition; pulse fast and weak, stupor, and rapid prostration. 

Endocarditis is the most frequent of the cardiac complications, occurring 
in more than half Church's cases. It is less frequent as first attacks occur 
later in life, but each attack increases the liability to it. It is rarely ulcer- 
ative. It is most frequently the first step in the series of morbid processes 
forming the common "heart disease." Peri and myocarditis occur with 
the preceding or separately. 

Pleurisy and pneumonia often attend the heart affections. Hyperemia 
of the lung, rapidly extending, may cause death in a short time. 

Delirium generally depends on hyperpyrexia; it may be active or typhoid. 
It occurs also with pericarditis. It has been attributed to sodium salicylate. 
Coma is a dangerous symptom; especially if not due to hyperpyrexia. 
Convulsions may precede coma. Chorea is most frequent in cases occurring 
in early childhood. Meningitis is rare, except with ulcerative endocarditis. 
Polyneuritis sometimes occurs. 

Several skin diseases have been described in connection with rheumatism, 
erythemas, urticaria, purpura, etc. Small nodules are found attached 
to the tendons and fascia, from a shot to a pea in size, especially about the 
hands and wrists. They remain for months, and are more common with 
children where they have diagnostic significance. 

The course of rheumatism is variable. Death may occur suddenly 
from myocarditis, or from embolism. Impure salicylates in huge doses 
may cause death. Delirium and coma occurring in acute forms in the 
young, are ominous. But with modern methods, the dangers are mostly 
in heart sequels. 



RHEUMATISM 129 

The diagnosis is not difficult if the definition of rheumatism is held in 
mind. Arthrites occurring with septic maladies rarely have acidity 
and the successive involvement of the joints. Suppuration also occurs 
with these forms, almost never in true rheumatism. Acute osteomyelitis 
near a joint may resemble it, but does not shift to other locations, and the 
septic symptoms soon develop. Acute arthritis of infants occurs earlier, 
remains at the hip affected, and suppurates. Gout first attacks small 
joints, the great toe notoriously, and tophi appear. Larger joints are only 
affected late in the history of the case; and the blood contains an excess of 
uric acid. 

The man who diagnosis ''everything that hurts" as rheumatism, 
including neuralgia, myalgia, gout, spinal irritation, septic arthrites and 
local affections, will have little success in his treatment. 

Arrange the night-clothes so as to facilitate easy changing, as tne sweats 
render frequent renewal desirable. Wool next the skin is thought to lessen 
the liability to cardiac disease. Sheets may be replaced by blankets. 
Frequent sponging with saturated solution of salicylic acid is grateful to 
the patient and useful — provided he is not moved, for every movement is 
agony. 

Don 't feed the patient on milk. Whether the disease depends on lactic 
acid or not, he will do better on other diet. Plain, strained vegetable 
or meat soups are useful, and suffice. Lemonade should be neutralized 
with soda, and given freely to make up for the great loss of fluid in sweating. 
Forbid alcohol absolutely, even if the patient has been long accustomed 
to a daily allowance. The beverage known as imperial is agreeable; 
made of potassium bitartrate and lemonade. 

Apply over the joints flannels saturated with solutions of salicylic acid 
or salicylate of soda, cover thickly and change often. Carded cotton or 
wool is grateful to the patient with exquisitely tender joints. When the 
disease tends to linger in one joint after the fever has subsided, a blister 
over it will do good. A pillow under a sore knee will give comfort; and if 
it can be applied, a splint to hold the joint immovable will be beneficial 
and comfort-giving. 

The more acute the attack, the more decided and prompt the relief 
afforded by salicylates. The usual method is to give soda salicylate, gr. 
20, every two hours till the fever falls and the pain is assuaged. The 
relief afforded has few equals in practical medicine. But possibly these 
large doses are unnecessary. If rheumatism is due to fermentation in the 
stomach this will be prevented by very small quantities of salicylate, as 
long as it is present. It is proposed therefore to administer gr. J of salicylic 
acid, salicylate of quinine, or resorcin — or any other antiseptic — for all 



i 3 o RHEUMATISM 

the successful remedies for rheumatism are significantly local antiseptics. 
This minute dose is given every five to fifteen minutes, so that there shall 
at all times, every moment, be present in the stomach enough to inhibit 
the activity of the acid-forming microorganisms. This is especialy 
valuable in subacute and chronic attacks, and in older patients, in wholm 
the ordinary salicylate medication is less useful than in acute cases in the 
young. Salol, salicin, aspirin, and other derivatives of this group, each 
has its field of usefulness, some persons bearing one and not the others. 
It does not do ior the doctor to become wedded to a single member of the 
group and forget the others. 

Fuller's alkaline treatment has the credit of preventing heart-diseases 
better than any other. He advised the carbonates as better borne in 
maximal doses than the bicarbonates. Dissolve an ounce of soda or potash 
carbonate in two quarts of water or more, and let the patient use it as a 
drink, a glass every hour, so as to take the whole during 24 hours, if the 
urine is not sooner alkaline; as soon as it is, lessen the dose to just enough 
to keep it alkaline. By this time the force of the attack and acuteness of 
the suffering will be broken. Keep the urine alkaline till the patient is 
restored to health. There is no objection to adding lemon juice to the 
alkaline water; it is pleasanter and as effective. 

When the malady lingers towards chronicity potassium iodide exerts 
a beneficent action it does not possess in earlier stages. An instance: 
A marine was transferred to the writer's care from his ship, with the 
special injunction not to give iodide, as it made him worse. With the 
curiosity of the man who touches fresh paint, the writer at once gave him 
iodide, and immediate improvement was the result. The dose is from 
30 to 60 grains a day, well-diluted. 

Cathartics are always useful. It has been said that the distress occa- 
sioned by their action exceeded the benefit; but the writer made special 
observations on this point and concluded that this was a mistake. Opiates 
are always harmful; temporary ease is followed by aggravation of the 
malady, and it tends under their influence to become chronic — the opium 
interfering with the natural evolution of the disease. 

Hyperpyrexia calls for local applications of ice or cold water. In 
some cases cold has been applied to the joints to relieve pain, with benefit. 
But usually heat does better. The chronic "rheumatism" of the aged 
is rarely rheumatic. Myalgia, adhesions about the tendons and muscles, 
and other maladies, account for these cases, and for the uselessness of 
anti-rheumatic remedies. Massage with hot oil is useful in them and to 
remove the " dregs" of true rheumatism. Patients recovering from 
rheumatism must obey the rules of hygiene to escape subsequent attacks. 



SMALLPOX 131 

SMALLPOX 

When the Arabs invaded Spain in the seventh century, they brought 
with them the group of eruptive fevers. These were at first looked upon 
as a single affection, but in time smallpox was separated, and later the 
rest were distinguished. Scarcely anyone escapes the liability to small- 
pox, one of the most contagious of diseases. Very rarely, indeed, second 
and even third attacks have been reported. When pregnant women are 
attacked the child may be born with the disease or its scars, or may be 
free and escape through vaccination. Smallpox is especially fatal to the 
lower races of man. 

The contagious principle is reproduced in the patient, and exists in 
the pus, excretions and exhalations from the skin and lungs. How early 
the contagium is active is unknown. It clings to infected rooms and 
clothing, and is carried by unaffected persons. How far it can be carried 
by the wind is uncertain. The writer has known the contagion to travel 
from a house on a street to one on an alley in the rear, a distance of over 
200 feet. The virulence of an attack depends on the condition of the 
recipient's blood, the hygienic surroundings (sometimes but little), and 
the severity of the case from which it is derived. But before the dis- 
covery of vaccination, when it was thought that no one could escape this 
malady, persons were accustomed to visit friends who had light attacks, 
in the hope of contracting it in like degree. 

Epidemics seem to gain with prevalence. For many years there had 
been but little smallpox in America, when shortly after the Spanish- 
American war numerous cases appeared over many states, so mild in 
character that it was not recognized. To this day many physicians per- 
sist in terming it Cuban itch, refusing to be convinced that it is atypic 
smallpox. But here and there it has developed under favoring conditions 
into the typic form with a mortality that gives one an awaking sense of 
what this disease was before vaccination had shorn it of its terrors. 

The specific cause of smallpox is as yet not certainly known. Cope- 
man has obtained sporelike masses, cultivated them in collodion capsules, 
and with them produced typical vaccine pustules in the calf. The prob- 
able cause is the protozoan, Cytoryctes variola, discovered by Guarnieri 
in 1892 and studied by Councilman in 1903. This organism is found 
in the skin, where it goes through sexual and nonsexual cycles. In vac- 
cinia it occurs only in the nonsexual form and hence is not reproduced 
in the infectious form. 

"A papule passing into the vesicular stage shows in the rete mucosum 
close to the true skin, an area in which the cells are smooth, granular, 



itf SMALLPOX 

and do not take the staining fluid. This represents a focus of coagula- 
tion necrosis, due according to Weigert, to the presence of micrococci. 
Around this area there is active inflammatory reaction, and in the vesicu- 
lar stage the rete mucosum presents reticuli or spaces which contain 
serum, leucocytes and fibrin filaments. The umbilication corresponds 
to the area of primary necrosis. In the stage of maturation the reticuli 
become filled with leucocytes and many of the cells of the rete mucosum 
become vesicular. The papillae of the true skin below the pustule are 
swollen and infiltrated with embryonic cells to a variable degree. If 
the suppuration extends into this layer scarring inevitably results; but 
if it is confined to the upper layer this does not necessarily follow. In 
the hemorrhagic cases red corpuscles pass out in large numbers from the 
vessels and occupy the vesicular spaces. They infiltrate also the deeper 
layers of the epidermis in the skin adjacent to the papules" (Osier). 

Pustules may appear in the mouth, pharynx, esophagus and even in 
the stomach. Peyer's patches may be swollen, and pustules have been 
seen in the rectum. They may be accompanied in the larynx by edema, 
croupous membrane, or necrosis of the cartilages. Pulmonary inflamma- 
tions are common. The liver may show diffuse hepatitis, fatty degenera- 
tion or small necroses. The red-blood cells clump, and leucocytosis is 
active. Cardiac inflammations and degenerations may be present; the 
spleen enlarges, the kidneys may show cloudy swelling and necrosed areas, 
nephritis is not unknown during convalescence; and orchitis is frequent. 

In the hemorrhagic form there are extravasations under the serous 
and mucous membranes and in the parenchyma of organs, the marrow, 
nerve sheaths, connective tissues, muscles, meninges, etc. 

Symptoms: — Three forms are described, the ordinary, hemorrhagic 
and modified or varioloid. Welch says that the incubation is twelve days, 
almost to the hour. 

The attack begins abruptly with a chill, or a convulsion in children. 
Headache and vomiting are severe, but the peculiar symptom is the intense 
aching in the lumbar region. Pains are also felt in the calves. The 
fever rises to 103 F. or more on the first day; the pulse fast and full. 
Delirium attends high fever. The patient is unusually restless, the face 
red, eyes bright, skin dry with a pungent heat, sweating being an occasional 
feature. Petechia? may appear, also rashes resembling measles and 
scarlatina. These are usually on the lower abdomen, inner thighs, under 
the arms and on the thorax adjoining. 

The eruption, if discrete, appears pretty accurately forty-eight hours 
after the initial chill; on the forehead and wrists, as small red papules 
feeling like shot under the skin. They follow on the face, extremities, 



SMALLPOX 133 

and a few on the trunk. Relief follows the eruption, and the fever falls. 
By the fifth day the papules have become vesicles, with a central depression 
or umbilication; by the eighth they have become pustules, the depression 
disappearing. As the pus appears the fever returns, and a red areola 
forms around each pock, with some swelling. Pain, tenderness and tension 
follow, and the eyelids may close. Leucocytosis is now marked. By 
the tenth or eleventh day the fever has begun to fall, the pustules to dry, 
and convalescence begins. Pitting from discrete smallpox is slight, unless 
itching induces the patient to scratch the pustules open. The chronology 
of the disease may be thus stated: 

First day: — Attack; chill or convulsion; primary fever. 

Third day: — Eruption; papule; remission. 

Fifth day: — Vesicle; umbilicated. 

Eighth day: — Pustule; secondary fever. 

Tenth day: — Defervescence. 

In the confluent form the eruption comes out a little earlier than in the 
discrete, the papules appearing early on the third day. In severe cases 
they are confluent from the first, but in the semi-comfluent they coalesce 
in the pustular stage. In all forms there is less of the eruption on the 
trunk, where the papules are generally discrete. The remission of fever 
is not so pronounced as in the discrete form. As the eruption becomes 
pustular fever returns, and the areolae about the pocks coalescing, we 
have continuous suppuration of the skin, with pain, tenderness and swell- 
ing. The temperature usually reaches 104 F., pulse 120; delirium is 
frequent and may be active. Patients occasionally escape from their 
nurses and create panic by appearing in public. The eruption in the 
mouth causes salivation; that in the larynx may endanger life by suffoca- 
tion. Diarrhea is more common in the young. Thirst is distressing. 
The lymphatic glands swell, especially in the neck. The eyes are closed 
and sight may be destroyed. The strength ebbs rapidly, and the typhoid 
state develops. The odor is dreadful; and with absorption of toxins from 
the skin causes the highest grade of toxemia. If the case is grave the pulse 
fails, delirium increases, diarrhea sets in, with subsultus and other 
evidences of an overwhelmed nervous system; or hemorrhages carry 
off the patient. From the eighth to the eleventh days is the period 
of danger. 

If the patient survives till the twelfth day tne pustuies begin to dry, 
the fever to subside, but toxemia continues. The pocks usually rupture, 
and with the access of air come microorganisms, which increase the ulcera- 
tion by which scabs are separated from the skin. Sometimes they coalesce 
and come off in casts of the hands and face. 



i 3 4 SMALLPOX 

A subvariety of the confluent form is known as corymbose. In it 
the eruption appears in groups, which are confluent, with patches of 
unaffected skin intervening. This is a specially dangerous form, the 
mortality being about 50 per cent. 

The term black smallpox is given to a hemorrhagic form in which the 
pocks contain blood from the first. Indeed, the patient may die before 
the eruption appears, overwhelmed by the force of the attack. In one 
such case coming under .the writer's notice the patient died on the second 
day and the eruption appeared after death. This form is more common 
in some epidemics than in others. It may be expected when the disease 
prevails in crowded tenements, with bad hygienic conditions, and especially 
in persons whose blood is vitiated by alcoholic indulgence and dissipation. 
But Osier says young and vigorous persons seem more liable to this form. 
This has not been the writer's experience, whose most typical case was a 
middle-aged, whisky-saturated prostitute. 

In the hemorrhagic form the malady begins with marked severity. 
On the second day an erythema appears, with blood points, often in 
the groins. This spreads, the points enlarging; ecchymoses appear in 
the eyes and on the mucosa. The skin may become almost universally 
purplish. Delirium is absent. Death is usual before the end of the 
week. Hematuria, hematemesis, hemoptysis and melena may occur. 
Women bleed from the genitals. The pulse is very rapid, the respiration 
fast and shallow. 

In another form the eruption appears as an ordinary one but becomes 
hemorrhagic in the vesicular or the pustular stage. These are grave 
but less so than those in which blood appears earlier. Mucous hemor- 
rhages are more frequent. Still, most of these die before the tenth day. 

In another group, the pocks become bloody in the vesicular stage, 
and abort quickly with speedy recovery. 

When persons who have been vaccinated contract smallpox it appears 
in a modified form known as varioloid. The attack may be as violent 
as the unmodified variety, with high fever, head and back ache, though 
usually it is much milder. The papules are few, the fever subsides as 
they appear, and the vesicles form little or no pus, so that secondary fever 
does not appear. Scarring is slight. Sometimes the vesicles dry into 
horny or warty masses without pus formation. 

It is claimed that there may even be varioloid without any eruption; 
cases during an epidemic occurring in persons exposed, who are seized 
with fever, back and headache, but recover in a few days. 

The complications of smallpox are few — it is enough in itself! They 
comprise laryngeal maladies, bronchitis, catarrhal or lobar pneumonia, 



SMALLPOX 135 

pleurisy, cardiac inflammations, parotitis, pseudodiphtheritic angina, 
and vomiting and diarrhea in children. Albuminuria is common, nephri- 
tis rare. Convulsions in children may end in fatal coma. Rare sequels 
are insanity, epilepsy, neuritis, myelitis, paralyses, ataxia, and various 
affections of the skin, such as acne, ecthyma and boils. Necrosis and 
arthritis occur. An apparent relapse has been described. Conjunc- 
tivitis is frequent and loss of one or both eyes was formerly common. 
Iritis and otitis media are less frequent. 

Scrofula was formerly very frequent after variola, and the writer has 
seen the worst cases coming thus; with abscesses, suppuration of lymphatic 
glands and of bone, ending fatally after years of suffering. 

When Svdenham overthrew the method of treatment based on the 

J 

idea of bringing out the eruption by heat, he reduced the mortality from 
something like 90 per cent to one-half of this. Black smallpox is always 
fatal; the corymbose kills 50 per cent; the confluent is especially fatal 
to the young; the dissipated and drunkards die; pregnant women nearly 
always die aborting. Hyperpyrexia and grave nervous implications are 
ominous. The degree of confluence on the face is a fair indication of the 
danger. Necrosis of the laryngeal cartilages is usually fatal. Pulmonary 
complications kill the children. 

Death occurs very early when the system is overwhelmed by the attack, 
as in hemorrhagic cases; otherwise the twelfth day is the most dangerous 
to life. 

The diagnosis is made by the chill or convulsion — the latter being 
especially significant in unprotected children who have been exposed. 
Headache and vomiting are generally present, but less diagnostic than 
the severity of the backache, which is the main evidence preceding the 
eruption. This, occurring on the third or fourth day, on the forehead 
at the roots of the hair and on the wrists, its shotty feel, indicate smallpox. 
The preliminary rashes may resemble scarlatina or measles so closely 
that a diagnosis is impossible until the true eruption appears. The writer 
has mistaken a syphilitic eruption of papules in a negro for smallpox, 
during its prevalence in the neighborhood. Chicken-pox may be dis- 
tinguished by the eruption occurring in crops, the pocks being of different 
sizes and shapes, and the history of exposure; but this takes time. The 
eruption of the little disease is most profuse on the trunk, it is not shotty 
and vesicles form quicker. 

Hemorrhagic forms may closely simulate cerebrospinal fever in chil- 
dren. Constitutional syphilis sometimes appears with fever accompany- 
ing a widespread eruption of papules, becoming pustular. Pustular 
glanders has been mistaken for smallpox. Impetigo contagiosa may 



136 SMALLPOX 

resemble the variolous eruption, but the absence of fever, the different 
course of the malady, and the easily traced contagion, serve to differentiate. 
But in any of the above the physician may have to wait some days to com- 
plete his diagnosis . 

Treafnie/Jf; — The patient should be immediately removed to the hos- 
pital for contagious diseases. It is impossible to prevent the spread of 
the malady otherwise, unless every possibly exposed person is properly 
vaccinated — and only those who have tried it know how difficult this is. 
For example: A prostitute died of what was afterwards determined to 
be hemorrhagic smallpox, but was certified as alcoholism at the time. 
A young man, a visitor of the woman, living a mile away, was seized with 
smallpox. All at his home were vaccinated, and all in the next two houses; 
but an unvaccinated babe in the third house was seized with the disease. 
Three families next were vaccinated, but in the fourth resided an anti- 
vaccinator, and he lost his wife and all his children. On the street next 
to that containing the house first affected, directly behind it, was an unvac- 
cinated child, which was also taken. The grandfather of one of the 
unvaccinated patients visited it, and carried the infection to another 
grandchild residing several miles away. In all, twenty-two cases came 
from the woman who died. 

The patient should be isolated in the sick-room, and the regime insti- 
tuted as described in the chapter on typhoid fever. The room must be 
kept cool, the patient not loaded with blankets, as the illiterate nurse will 
assuredly do, to " bring the rash out." Isolation must be absolute, also 
the disinfection of dishes, linen, and all other objects used by the patient, 
before they leave the sick-room. The nurse must have a suitable cover 
for her clothes, which can be taken off before she leaves the room. All 
unprotected persons must be sent out of the house. Strict quarantine 
should be maintained. 

For the good of the patient, ventilation must be of the freest, although 
this adds to the danger of transmitting contagion. 

Welch says that vaccinia does not exert its prophylactic power until 
the red areola appears around the point of insertion of the virus. When 
a person has contracted smallpox, if vaccinated so early that this areola 
appears before the smallpox has shown any symptoms, the attack may 
be entirely prevented. If not, but the areola appears before the smallpox 
eruption come out, the attack may be mitigated in severity. The areola 
appears on the seventh or eighth day after vaccination; the outbreak of 
smallpox occurs on the tenth day after infection. Vaccination performed 
within three days after smallpox infection may therefore prevent the attack 
of the latter, or if done within three days more may favorably modify the 



Smallpox i 37 

disease. Every day after the infection has occurred, that elapses before 
vaccination is done, lessens its modifying influence. The degree of pro- 
tection thus afforded varies in different individuals. Revaccination takes 
effect quicker and is more effective than primary vaccination. Human 
virus takes effect quicker than bovine; and Welch prefers eight-day 
lymph. Waterhouse believed that multiple insertions hastened the vac- 
cination. To ensure success Welch advises the use of several lymphs 
and revaccination daily until success is evident. Forty-seven persons 
vaccinated by him for the first time, after exposure at the smallpox hos- 
pital, were perfectly protected against the disease. 

The usual toilet of the bowels, and remedies for fever, are indicated. 

The weight of evidence favors the claim that saturation with calcium 
sulphide inhibits the action of the protozoan. If this is quickly accom- 
plished (by administering a grain of the salt every half to one hour till 
the perspiration exhales the odor of sulphydric acid, then enough to sus- 
tain this effect), the subsequent course is modified, secondary fever does 
not arise, as the suppuration on which it depends is checked, and abortive 
forms appear. The remedy is harmless in any event; but if it is given 
during vaccination it prevents the development of the latter as well. 

Tepid baths are useful when the case is not too severe to be handled, 
and zinc sulphocarbolate may be added to the water, gr. x to Oj, being 
especially suitable as antiseptic and non-toxic. The temperature of the 
bath should be about 105 F. to begin with, gradually cooled by adding 
cold water until the patient's temperature has been reduced as desirable. 

It is not likely that there will be any irritability of the stomach if the 
bowels have been emptied and renal elimination is kept up. If there is, 
it may be allayed by sips of carbonated water, small pellets of ice, or by 
cocaine, gr. 1-6, repeated hourly. Cool, wet compresses to the face are 
grateful. Headache means toxemia; it calls for eliminants. Insomnia 
and delirium are controlled best by hyoscine hydrobromate, gr. 1-100, 
hypodermically; or nickel bromide, or camphor monobromide, the latter in 
depressed cases. Either should be given to effect — gr. 1-6 to j every 
half -hour. Caffeine valerianate, gr. 1-6 half -hourly, meets the indication 
admirably in many cases of depressed irritability. 

Convulsions indicate hyperpyrexia or deficient elimination; the reme- 
dies being cold to the head and entire body, or pilocarpine hypodermics, 
or vera trine enough to subdue vascular tension, or saline solution, 1-2 
pint, thrown into the colon to flush the kidneys. These remedies will 
usually relieve the lumbar pain; or macrotin may be given, a grain every 
hour. Welch condemns rubefacients strongly as increasing the eruption 
and the danger. No derivation is thus secured. 



138 SMALLPOX 

The diet during the first stage should consist of bland fluids alon 
milk, clear broth, albumen water, fruit juices, lemonade, effervescent 
saline laxative, may be employed as beverages throughout. If depression 
is marked, raw beef fluids such as bovinine and sanguiferrin may be 
administered in small and frequent doses. 

The above treatment should be continued during the eruptive stage. 
Depression may render it advisable to employ warm baths, if the extremi- 
ties are cool, especially with children. Hot broths and teas containing a 
little capsicum are also then advisable, and it must be recollected that in 
children convulsions have a different meaning from those of adults. Dan- 
gerous depression of vitality must be foreseen and quickly remedied. 
Implication of the throat may lender concentrated or strongly tasting 
medicines unbearable; the mouth and throat, as well as the nasal pas- 
sages, should be frequently cleansed with some mild antiseptic solution. 
Welch recommends flaxseed lemonade. Mild cocaine sprays may be 
required to enable the patient to swallow food. Pellets of ice dissolved 
in the mouth are also grateful. Menthol tablets used as lozenges are 
relished by many. There will be less glandular swelling in the neck, 
the better the cleansing of the mouth and throat is done; if annoying, it 
may require cold compresses or ice-bags. These must not be too steadily 
applied. Hot applications are preferred by many patients, and are equally 
good. Dilute chlorine water is a useful lotion for fetor. Edema of the 
glottis may necessitate intubation or even tracheotomy. , 

With suppurative fever insomnia and delirium may appear, especially 
if the bowels have not been kept clear and disinfected, and renal elimina- 
tion maintained. We must ask our readers' pardon for so frequently 
repeating these words — but in truth it is necessary to do so that their vital 
importance may not be forgotten. To the hyoscine it may be necessary 
to add cicutine hydrobromate, or gelseminine also, if the delirium be 
fierce. Give enough to control the symptoms. Cicutine, gr. 1-67, with 
gr. 1-250 of each of the others, every hour till effect, is possibly an average 
dose. But if the pulse be strong or the kidneys fail, veratrine is needed — 
to effect. The patient must be carefully watched in this stage, as he 
may get away and do irreparable harm to himself or to others. 

In hemorrhagic forms Welch has little expectation of benefit from 
acids, quinine, ergot, or iron. Indicating profound toxemia or an attack 
by the protozoa on the red blood cells, remedies for sustaining the vital 
forces are indicated. Strychnine arsenate and unclein in fullest doses are our 
chief reliance, giving the former as far as the pulse indicates as proper, 
and the latter up to a dram a day of the standard solution. Echinacea 
should be useful if the claims of its advocates are well-founded — it is at 



SMALLPOX i 39 

least harmless and may be given on ihc possibility of benefit. Cocaine 
has proved valuable in purpura hemorrhagica and may be tried here. 
The old hemostatics have all been fully tried and found useless. 

Welch has little to say in favor of the bath treatment of smallpox — 
it is difficult in the suppurative stages and not efficient. Cold compresses 
and sponging are useful. The continuous bath offers some advantages; 
the patient's temperature may thus be sustained at any desired point, 
and the water being impregnated with antiseptics may oppose the infective 
processes in the skin. One young man was kept in the bath for five days, 
the temperature remaining at ioo° F.; but on removing him it rose to 
103 F. and he died of systemic poisoning that had not been prevented 
by the immersion. This well illustrates the limitations of the bath sys- 
tem — in all maladies — it combats a symptom, but the disease goes on. 

Vital depression is indicated by pallor and shrinking of the face and 
hands, rapid, feeble pulse, tremors, subsultus tendinum, dry tongue, 
delirium, and worst of all by dilating pupils. The enormous loss by 
free suppuration fully accounts for this condition. The wise physician 
will fortify his patient against it by careful nutrition during the early 
stages, the free use of nuclein and cardiac tonics as soon as their indication 
is presented, and by the use of the sulphide of lime to restrain the destruc- 
tion of tissue. Throughout the disease food should be administered in 
small quantities at intervals of four hours, with a small cup of coffee 
between each two doses. We do not believe in the value of alcohol or 
use it in any form or case of this malady; Welch's great authority to the 
contrary. Whenever it is possible no drugs should be given by the stomach 
that could possibly irritate it; the hypodermic method will render this 
unnecessary in most instances, and nuclein may be dropped on the tongue 
and absorbed from the mouth. The rectum is a poor way to introduce 
food or medicine, but the vagina absorbs much better. Wool tampons 
introduced in it will convey a good deal of bovinine into the system. 

As a rule the swollen eyes are best treated by cold compresses, though 
leeches may rarely be advisable. Hot compresses are often preferred. 
As soon as possible boric lotions should be applied, frequently. Hemor- 
rhage from the nostrils may be checked by chromic acid solutions, as in 
diphtheria. Ointments applied to the lids prevent adhesion. For con- 
junctivitis silver solutions are advisable. 

The same treatment should be continued during the stage of decline, 
tonics gradually replacing antipyretics. Quinine hydroferrocyanate, 
gr. 1-6, every two hours, is a valuable remedy, combating sepsis and restor- 
ing the crasis of the blood. The diet list may be carefully enlarged by 
the addition of mild farinacea, toast, custards, eggs and junket — the latter 



140 VACCINATION 

is useful throughout. Diarrhea may require a few doses of zinc or calcium 
sulphocarbolate — enough to control it. If obstinate, add cotoin or silver 
oxide, quantum sufficet. Edema of dependent parts calls for tincture of 
chloride of iron, or for berberine and calcium lactophosphate — the one 
to restore connective tissue tone, the other to rebuild the fragile cell walls. 

The importance of these remedies is too great to be overlooked. Much 
future trouble is avoided by their judicious application. Iron cannot be 
"rushed" now; quinine destroys protoplasm, and it cannot be spared; 
strychnine has been employed during the crisis and may now be replaced 
by brucine. It seems probably that bebeerine, standing between quinine 
and berberine, might be applicable here. 

There is a vast rush of debris to the eliminant organs, and these must 
not become clogged. The vegetable, non-debilitating stimulants of the 
lymphatic system, stillingin and phytolaccin, should prove of value. Atten- 
tion to this will aid in preventing abscesses and other disagreeable sequels. 

While Finsen strongly advocated the red light treatment of smallpox, 
Brayton observed no benefit in 300 cases so treated. Serums have failed. 

To allay itching apply linseed oil and lime water, weak phenol or 
thymol ointments in petrolatum, or cold compresses. Hot compresses 
are more agreeable in some cases. Discharging pus should be removed 
by any mild antiseptic lotion, and dusting powders applied to allay fetor. 

Many devices have been advocated to prevent pitting. Welch has 
had the fullest opportunities of, trying these and he doubts if anything 
accomplishes this object. Possibly painting with pure tincture of iodine 
may be an exception; he thinks it shrinks the pustules, hastens decrusta- 
tion and lessens pitting, diminishing the liability to subsequent suppura- 
tion and completely destroying the odor from that portion of the skin to 
which the iodine is applied. Sodium bicarbonate with petrolatum softens 
the scabs, and antiseptic baths aid in their removal. 

The conjunctiva may require snipping, or canthotomy be needed, to 
relieve pressure on the eye or facilitate examination and treatment. Ulcera- 
tion of the cornea requires the service of a specialist, or the special knowl- 
edge to be obtained from works on that specialty. 

VACCINATION 

Jenner began to vaccinate in 1796, having discovered the popular 
belief in the efficacy of cowpox some years previously. The discovery 
was received with the most virulent and determined opposition. Its 
innate absurdity appealed to the numerous class who measure every new 
idea by presumption of the completeness of their preexisting knowledge. 



VACCINATION 141 

As there was not a solitary fact then known with which the idea of vac- 
cination could be assimilated, it must be wrong. The venomous ani- 
mosity with which Waterhouse was persecuted for bringing vaccination 
to America, must ever be a consolation and support for those who meet 
similar abuse for endeavoring to enlighten the medical profession. The 
Bible was of course levied upon for material, and the highly lucid argu- 
ment adduced, that the "mark of the Beast" in Revelation meant vaccina- 
tion! To this day the opposition persists, and Antivaccination Societies 
exist, as monuments of human wrongheadedness and incapacity for 
impartial, logical, truthful reasoning. 

What is vaccinia? Several experimenters vaccinated calves with 
smallpox, and produced typical vaccine virus. Others did the same 
thing, but the virus produced caused genuine smallpox. There is a lapsus 
here in our knowledge. The view now held is that vaccinia is smallpox 
modified by transmission through the body of the inferior animal, only 
the non-sexual forms of the parasite being present. 

When the vaccine virus has been introduced there is a little irritation 
caused by the scratching, w T hich subsides in a short time. Much irrita- 
tion or suppuration is an evidence o£ contamination of the virus with 
pathogenic microorganisms; and if the irritation has subsided at the end 
of a week, this is to be considered a false vaccination, and the operation 
should be done over. If successful, there is no irritation until the third 
to the sixth day; if the virus is weak, not till the eighth day. Then a 
small red papule appears, like a shot under the skin. By the eighth or 
ninth day a red areola has developed around it, and the papule has become 
a pearly vesicle — the ' pearl upon a roseleaf . ' The vesicle may be from 
a line to half an inch in diameter, or much larger if a large surface has 
been denuded of epithelium and plenty of virus applied, so as to form a 
number of coalescing vesicles. The vesicle is umbilicated, and resembles 
closely a true smallpox vesicle. The areola may be three inches in 
diameter. The glands in the axilla are tender and swollen — if the vac- 
cination has been done on the arm — and there is fever rising to 100 or 
104 F. This lasts one or more days, and as the vesicle dries the fever 
subsides. The vesicle becomes a pustule, loses its umbilication, and if 
irritated often breaks and its contents are exuded. They may erode the 
skin, or be transferred by scratching to any part of the patient's body 
within reach, even to the eyes, where they may do great harm. 

In one of the writer's cases an unruly child transferred the virus, 
which had just been applied to his arm, to his eyes, where it took 
effect. The result was a permanent opacity, for which the vaccinator 
was blamed. 



i 4 2 VACCINATION 

The local inflammation may be great, the arm stiff and painful, and the 
hand held several inches from it feels heat radiating from it. There is 
decided leucocytosis. The pustule dries into a scab, which may be 
loosened and removed about the 15th day, or may adhere a week 
more. There is left a scar which becomes white in time, with depres- 
sions like the mark made by pressing a thimble against the skin. 
If the scab has been loosened by ulceration the scar may be radiating 
with no thimble-pitting. As the scab forms there is much itching, 
but not so much as with spurious vaccinations. The latter appear 
earlier and are well on to recovery at the end of a week from the 
vaccination. 

Children who are eczematous but have not yet shown the eruption, 
will have an outbreak when the constitutional symptoms are present. For 
instance in a family where all the children had eczema when the first teeth 
were cut, the writer vaccinated a baby before it had any teeth; and the 
family eczema appeared. A popular but homely way of expressing 
this is, that "whatever is in the child will come out with the vaccination." 
Erythema or erysipelas may occur, if asepsis is not secured. A physician 
on a hot July day vaccinated 20 persons, first rubbing up a scab on a 
glass plate and adding a drop of water for each operation. On the next 
day he vaccinated 20 more, with what was left of the same virus. Every 
person vaccinated on the second day had erysipelas. Want of proper 
precaution may result in contamination of the virus with tetanus, impetigo 
contagiosa, syphilis, varicella, or tuberculosis. Or, the virus being pure, 
any of these may enter the sore if opened and contaminated. Urticaria, 
lichen, and other non-contagious maladies may be aroused by the operation. 
The glands may go on to suppuration if pyogenic germs enter. There 
is no reason to doubt that scarlatina and measles may be transmitted by 
vaccination, though the writer has never known of a case. Here is an 
instance of the manner in which popular prejudice against vaccination 
arises: He vaccinated 25 children in a public school. Next day one of 
them was taken with scarlatina, and the case was reported as due to vacci- 
nation. But the record showed that the virus had been taken from a child 
who was free from scarlatina; 24 others vaccinated from the same virus 
were found free from scarlatina; the period of incubation was too short; 
and finally it was shown that the child who sat in the seat next to the patient 
had been at home with scarlatina, and was almost certainly the source of 
infection. And yet that case was heralded by the antivaccinators as an 
instance of bad vaccination. 

Occasionally pneumonia has developed during the febrile period. 
Whether there was any connection between this and the vaccination is 



VACCINATION 143 

uncertain. As this occurred five times after over 10,000 vaccinations, it is 
a question if that many pneumonias would not have occurred without the 
operation in that length of time — a month. If they were due to an 
accidental infection with the pneumococcus this is an addition to our 
knowledge, as we know of no successful inoculations with this organism. 
The writer looks on the association as accidental. 

Fainting sometimes occurs from the operation. The writer looked upon 
this as nervous until chance led him to the true cause. The vaccine 
scab taken from the arm of a child is composed of two parts, separated by 
a partition; the part outside containing the vaccine lymph, that next the 
arm being simply dried pus. Not knowing this, he used under the surface 
of a crust for vaccinating, and several patients fainted during the operation, 
in succession. He then employed the outer part of the same crust, and not 
one fainted. This observation was verified by subsequent trials. The 
pus that caused fainting also caused several suppurations of axillary glands, 
and did not produce true vaccinations. 

What, then, are the objections to vaccination? Before replying to this 
question, the writer desires to state how he comes to have the right to reply 
to it. For five years he held a vaccine district in an eastern city. During 
this period he visited every house in the district from two to four times a 
year, and when a case of smallpox occurred he again visited every house 
within a block. In this time he vaccinated over 10,000 of the people and 
influenced nearly all the rest to be vaccinated when they needed it. Every 
case of smallpox was reported to him; every one vaccinated was seen 
by him a week after the operation and again a week later. In this way 
every case of supposed harm from vaccination w T as brought to his attention, 
and he had every opportunity to judge of the effects, immediate and remote, 
and of the degree to which immunity against smallpox was conferred by it. 

But two cases occurred in which injury of more than transient and 
unimportant character ensued. In one, a girl vaccinated with bovine virus 
was inoculated with tubercle, from which she died a year later. The house 
supplying this virus went out of the business on account of the investigation 
following. The other was a spoiled child who resisted vaccination, wiped 
the virus from his arm and at once transferred it to his eye. The vaccination 
" took" on the cornea, leaving an opacity. The sight was impaired slightly. 

On the other hand, there were some curious instances in which the 
vaccination was actually followed by improvement of health. In one case, 
a boy of eight years had been so puny that he had never been sent to 
school. When the vaccination took, an erythema broke out over his body, 
and a complete change took place, so that when the writer saw him a year 
afterward the mother proudly boasted that the boy "thrashed every other 



144 VACCINATION 

child in the block." Many children were brought by their mothers, 
Germans mostly, to be vaccinated to cure whooping-cough. The results 
were sufficiently satisfactory to make the practice customary. 

The writer has never seen a case of syphilis due to vaccination, though 
many supposed cases have been referred to him as an expert. That such 
cases have occurred is established, but every one so referred to him turned 
out to be some harmless skin affection, for the most part non-transmissible 
like eczema. If there is a tendency to scrofula in a child, it will be aroused 
by vaccination; since variola was a great cause of scrofula. In such cases 
it is wise to postpone vaccination until the health is well established, unless 
there is immediate danger of smallpox infection, when the lesser of two 
dangers is to be chosen. 

What of the immunity conferred by vaccination? At first Jenner 
proclaimed absolute and eternal immunity; but before he died he advised 
revaccination every year. Human beings differ in this as in most respects. 
With some a single vaccination seems to forever exhaust the susceptibility; 
with others immunity expires in a longer or shorter time. Some persons 
once vaccinated will never take again; while others will take well in a year. 
The only way to tell if the old vaccination is yet protective is to revaccinate 
whenever there is danger of smallpox. If a revaccination will not take, 
much less will smallpox, for the writer has produced good vaccinations 
on persons who had had smallpox. Surgeon E. D. Payne, U. S. Navy, 
employed immediate revaccination, as soon as the preceding had healed. 
This was repeated until there was no longer any reaction; and such persons 
proved immune when exposed to smallpox. This we believe to be the best 
method, as in this way we may be sure that there is no longer any liability 
unexhausted. 

Lymph from the calf is now employed universally in preference to that 
from the child. There is no danger of syphilis in calf lymph, and but little 
of tubercle. In the case mentioned, there seemed to be an infection of the 
premises where the lymph was taken and stored. After the points had been 
charged with lymph they were placed in a drying box, but after 48 hours 
it was found that the lymph had not dried. This liquefaction of. the 
lymph recalled an observation of Reynolds that tubercular sputa ejected 
into a handkerchief did not dry but remained wet, while non-tubercular 
sputa soon dried. 

The Chicago Health Department tests its virus bacteriologically for 
purity and freedom from pathogenic germs, and again tests for potency. 
The result is a sure and safe virus — the only sort fit for use. Were such 
precautions taken with all virus used, there would be fewer antivaccinators to 
prevent perfect protection of the community and eradication of smallpox. 



VARICELLA. 145 

In vaccinating, the only advantage in selecting the arm, near but not 
directly over the insertion of the deltoid, is that as we always look there 
to see if one has been vaccinated, it simplifies this examination. Wash 
the skin with soap and water, then with alcohol, and then with a sterile 
instrument scarify or scrape so as to uncover the secreting surface of the 
true skin; then apply the virus, and cover to exclude tetanus and other 
malefic germs. If the blood is drawn it hinders absorption and frightens 
the child. It is not necessary to cause pain. Let the surface dry before 
replacing the clothing, or the virus may be rubbed off. When the inflam- 
mation is present no dressing equals cool compresses, changed as desired. 
A few granules of aconitine, with a saline laxative, are all the medication 
required. 

Perfect vaccination is a perfect protection against smallpox. 

Revaccinate whenever there is smallpox in the neighborhood. 

Do not try to argue with an antivaccinator. He is beyond the reach of 
reason, and incapable of telling the truth. 

VARICELLA 

There is no connection between varicella and variola except that the 
former occasionally confuses the diagnosis of mild cases of the latter. 
Chicken-pox occurs from contagion, and in most cases this may be traced. 
It is most common in childhood. 

The incubation lasts 10 to 15 days, with no symptoms. The attack 
commences with a chill, fever, vomiting, or aching in the back or legs. The 
eruption appears within 24 hours, on the back or chest, sometimes on the 
face. It appears as papules, changing in a few hours to vesicles, containing 
a clear fluid soon becoming turbid. The vesicles are of various size and 
shape, not uniform as with smallpox; some but not all are umbilicated; 
they are rather oval than round; there is little or no inflammatory areola 
surrounding them; they become purulent within two days, and then dry 
up, falling off before the fifth day as brown scabs, leaving no scar unless 
scratched open. Fresh crops appear, so that some are papules while others 
are vesicles, pustules and scabs. They are never confluent. They vary 
from a few to hundreds. Sometimes a scarlatiniform rash precedes the 
true eruption. They may come on the mouth and laryngeal mucosa. 
Sometimes the eruption comes in large bulla?. The fever is slight. In 
strumous children gangrene of the skin or scrotum has occurred. Hemor- 
rhagic cases have been recorded, with mucous hemorrhages and cutaneous 
ecchymoses. Nephritis and paralysis are rare sequels. Death has resulted 
from the general eruption. The writer lost a child from meningitis suddenly 



146 SCARLATINA 

developing during an attack of varicella. Second and even third attacks 
have occurred, though as a rule it is self-protective. 

The diagnosis is easy, from the description given. The multiform erup- 
tion always distinguishes it from smallpox even when no history is attainable. 

Treatment: — Empty the bowels with calomel, gr. 1-6, followed by saline 
laxative; then follow with aconitine for fever, and phenol lotions to allay 
itching and prevent scratching. Give plenty of water, see that elimination 
is free, ventilate well, and feed with mild, non-irritant fluids. 

SCARLATINA 

Sydenham contemptuously termed this the "name of a disease." We 
are far from looking upon it in such a light, for scarlet fever shares with 
diphtheria the dread of parent and physician as among the most dangerous 
and treacherous of diseases. Since vaccination has put an end to the huge 
mortality of smallpox, there are many more subjects left for scarlatina, and 
the deaths from it have greatly increased. It is one of the most contagious 
of diseases. Children are affected mostly, but all ages are liable; one of 
our Admirals having been seized with it some years ago, scattering the 
officers ' families in terror from the naval rendezvous at Port Royal. Cases 
occur at all seasons, in both sexes alike, but some persons appear to be 
immune. 

The contagion is carried on clothing. A lady visited her niece, ill 
with scarlatina; the sick child climbed into her lap; on returning to her home 
her own child did the same thing, and contracted a fatal attack. 

A child recovered from this malady, and the family being anxious to. 
avoid it in their other children, who had been sent out of the house, employed 
an expert to supervise the disinfection and fumigation, which were done 
regardless of cost. The children came home, and promptly went down 
with the disease. Reviewing the means employed to ascertain where the 
failure had come in, the expert noticed that the mother had very heavy hair. 
Inquiry showed that she had not disinfected it; and as she had nursed the 
first sick child, the source of contagion was evident. 

The contagion lasts long. A man died of scarlatina in a mountain 
hamlet in Pennsylvania. His clothes were placed in a trunk in the garret. 
Twenty-five years afterwards his daughter got them down and cut from 
them a suit for her son; who in due time took down with scarlatina. At the 
time there was no case in the neighborhood, nor had there been any commu- 
nication with any place where it prevailed. 

The contagion probably is present from the first, even during the 
incubation. It exists in the first desquamation, but if successive coats 



SCARLATINA 147 

are thrown off, only the first carries it. It is also carried in milk. It is 
generally self-protective, but second attacks have been reported. Surgical 
and puerperal scarlatinas are probably septicemias. 

No specific lesions are found after death; the anatomy of scarlatina is 
exclusively living anatomy. The throat may show ulceration or membranous 
deposits, the cervical glands may be enlarged or suppurative; the pharynx, 
stomach and intestines may be catarrhal; the liver show interstitial degen- 
eration, the spleen enlarged, cardiac inflammations may occur, and there 
is often nephritis. Catarrhal pneumonia is a common complication. 

The incubation varies from a day to a week. The invasion is abrupt, 
with irritation of the stomach or convulsions; fever rising quickly to 105 
or to a much higher point in a few hours. The skin is dry and radiates 
pungent heat. The tongue is coated, the mouth dry; cough is usual, the 
face flushed and the child incessantly calls for water. 

The eruption comes out on the next day, as a general flush with deep 
red pin-points, on the neck and chest, spreading over the whole body within 
a few hours. After two to three days it begins to fade. The skin seems of 
a uniform scarlet but close examination shows it to be mottled. It 'is 
swollen also. Press the finger firmly on it, and the white spot is almost 
immediately rosy when the pressure is removed. Hemorrhagic points, 
sudamina and milia may appear. The eruption occurs also on the soft 
palate. Large petechias form in malignant cases. The child complains 
of burning and itching. The entire skin may not be affected, and there 
is even a form with no eruption. The tongue is red at the tip and edges, 
small, pointed, the enlarged papillae projecting like the seeds of a strawberry. 
The fur peels off leaving the whole tongue red. The breath has a heavy- 
sweet odor. 

The soft palate, tonsils and pharynx are early in the disease red and 
punctate. In some cases the tissues are swollen, and in others the angina 
simulates diphtheria. In these about the seventh or eighth day the breath 
becomes offensive, and the tonsils are found to be covered with a pultaceous 
deposit, resembling the false membrane of diphtheria. Like the latter 
the local disease may spread forward into the mouth, up into the nose, out 
into the antrum, the malar bones, the nasal ducts to the eyes, the eustachian 
tubes to the ears, rarely into the pharynx and very rarely the esophagus 
and stomach. The parotids and cervical lymphatic glands are affected, 
and apt to suppurate. The whole of this vast region may be affected as 
in diphtheria, the tissues necrosing and all pouring out quantities of corrosive 
matter, whose stench is so great that strong men faint when brought into 
the sick-room. The ear-drums may be perforated and hearing destroyed, 
the malar bones necrose and be cast off whole, the corners of the mouth 



148 SCARLATINA 

ulcerate, and epistaxis may set in and carry off the patient. In one case, 
an infant a year old, the writer found fluctuation in the region of a parotid. 
This was in 1876. Diligent search of the text-books of the day elicited 
the advice to let the collection alone; and the whole skin from the right ear 
to near the left one, and the ramus of the jaw to the clavicle, sloughed off, 
with the connective tissue. The little muscles of the neck could be lifted 
up on a probe as easily as if dissected out — as in truth they were. The 
carotid was seen pulsating, the sheath gone. The family lived in the garret 
of a tenement; and just then the mother presented the whisky-saturated 
father with another babe. One-tenth the disease would have killed a 
millionaire 's child, but naturally under the circumstances this one recovered ; 
and it was one of the great surprises of the physician to see the rapidity 
with which the tissues were regenerated and the huge gap filled in. But 
never again did he allow such an abscess to go an hour without opening it. 

The fever is very high; in but one other malady can it go so high and 
recovery ensue. It is not unusual to see it reach 104 the first day, and the 
writer has recorded 112 in one case. The pulse is also high, reaching 140 
in many cases that recover. Respiration is also rapid. The fever rises 
when the rash comes out. The nervous symptoms are few and limited 
to headache and delirium from fever, unless the toxemia of angina causes 
hebetude. The digestive system is usually in fairly good shape. The 
urine is red and scanty, showing albumin early, with hyaline casts. 

When the rash has been out for three days it begins to fade and the 
skin feels rough. Desquamation comes on, the skin shedding its epithelium 
in scales or flakes, that of the hands sometimes coming off entire. The 
hair and nails may be shed. Desquamation is completed within three 
weeks from the onset of the attack, but it may be repeated several times. 

Leucocytosis is present. Sometimes when one child in a family has 
scarlatina others in the household may be slightly ill for a few days, with 
sore-throat and slight fever, possibly no perceptible rash, and yet be thence- 
forth immune against this malady. 

On the other hand in some cases the poison is so intense that the patient 's 
vitality is overwhelmed by the attack, and death supervenes in a few hours. 
One of the writer's patients was seized with a convulsion at 11 a. m., and 
died at 3 p. m. the same day, having never regained consciousness. 

Sometimes the blood is disorganized by the toxins, and petechias appear 
and enlarge, hemorrhages occur from the mucous membranes, and death 
comes on the second or third day. 

The most important sequel is acute nephritis; occurring during conva- 
lescence. The albuminuria does not cease but increases, during deferves- 
cence and desquamation, or it develops then first. It may follow a mild 



SCARLATINA 149 

attack, even so mild that it is unnoticed and only recollected or recog- 
nized when nephritis supervenes. The sooner it comes, the greater is 
the severity. In the worst cases there is scarcely any urine passed, con- 
sisting of blood, albumin and casts mainly. Total suppression is rare. 
Vomiting is incessant and uremia may cause speedy death with convul- 
sions. In ordinary cases there is general edema, urine scanty, smoky, 
highly albuminous, with many casts. Anasarca may be extreme, the 
whole body swelled like a cushion. Respiration is hindered. Some die 
of uremia, others linger until the malady becomes chronic, but most 
recover. Other cases are quite mild and may be neglected by the incau- 
tious physician, but these are liable to become acute and even fatal with 
brief warning. There is a tendency to effusion and any of the serous 
cavities may fill up suddenly. 

A joint affection simulating rheumatism sometimes occurs during 
convalescence, probably septic, which may go on to suppuration. Usually 
but one joint is affected. 

Any of the cardiac inflammations may occur, with arthritis or alone, 
and ulcerative endocarditis has been recorded. Pleurisy, pneumonia and 
empyema, are not uncommon. Scarlatina is one of the most common causes 
of deafness not congenital. Facial paralysis may attend from implication 
of the facial nerve. Convulsions followed by hemiplegia, ascending 
myelitis and chorea, are sometimes sequels. Cerebral thrombosis and 
mental aberration are rare. As occasional sequels may be mentioned 
edema of isolated parts like the eyelids, symmetrical gangrene, enteritis, 
noma, ulceration of the soft palate and dry gangrene. 

Diagnosis: — The most difficult affection to distinguish is an acute 
exfoliative dermatitis, which comes on suddenly, spreads over the whole 
body rapidly, lasts five days and desquamates. The throat is not affected. 
It may recur any number of times. Occurring in an epidemic of scarlatina 
it could not be distinguished from the latter. 

In measles the rash does not appear until the fourth day; it is arranged 
in crescents, is in larger papules, appears first on the face, has no sore throat 
but the pillars of the fauces and soft palate are stained a mulberry tint, 
there is no leucocytosis and Koplik's sign is present. The bronchitis is 
prominent, the odor peculiar, like "a freshly picked goose," the eyes 
injected. In rcetheln the rash does not reach its acme all over the body 
at the same time; and the symptoms otherwise follow measles. 

Surgical scarlatina maybe the true form, septic, or exfoliative dermatitis. 

Diphtheria is not nearly so contagious as scarlatina; the throat affec- 
tion may be very like, or even identical when there has been this malady 
superadded to the scarlatina. The characteristic eruption is wanting in 



IS© SCARLATINA 

true diphtheria if primary, and the bacteriologist finds Lcefner's bacil- 
lus. The writer believes the angina is not always diphtheritic because 
he has obtained benefit from salicylic solutions in scarlatina much 
superior to those obtainable from this agent in diphtheria. Some- 
times the diagnosis is exceedingly difficult when the diphtheritic rash 
closely simulates that of scarlatina. A study of the course and spread 
of the malady may be necessary for complete differentiation. Fortunately, 
there is little difference in the treatment. Drug rashes are recognizable 
as being usually partial, transient, non-typical, febrile, and follow bella- 
donna, quinine, iodides, etc. 

Diphtheria, varicella, whooping-cough, erysipelas, typhoid and even 
typhus may coexist with scarlatina. 

The infection lasts until the first desquamation is complete. Cases 
indicating a longer infection are probably due to infection of the clothing 
or dwelling, where as has been shown, the poison may exist in unimpaired 
virulence for many years. 

Epidemics differ greatly in their virulence, but bad hygienic conditions 
can at any time generate malignancy. The mortality varies from 5 to 30 
per cent. The danger is greater in the young. Hyperpyrexia, early 
nervous symptoms, hemorrhages, bad breath, parotitis or cervical adenitis, 
laryngeal complications and the extension of the pharyngeal malady to 
any of the mucous tracts communicating with the nasopharynx, are bad 
signs. Nephritis is dangerous in proportion to its acuteness and the degree 
of renal failure. 

Treatment: — There is no disease of equal severity and danger in which 
the efforts of an alert, competent physician are more richly rewarded. 
Isolate the child at once, in a well-ventilated room, and send all other 
unprotected persons out of the house. The arrangement of the sick-room 
is that already described under the head of typhoid fever, to which the 
reader is referred. Ventilation cannot be too free for the patient's benefit, 
though it adds to the danger of neighbors. 

Absolutely, the first duty of the physician is to see to putting the hygiene 
of the house and vicinity in perfect order. The writer had the opportunity 
once to study over 2,000 cases of infectious diseases in one year — typhoid, 
scarlatina and diphtheria — and he was impressed with the certainty with 
which malignancy followed bad hygienic conditions; and not any occult 
"sewer gas," but visible, palpable and " smellable " collections of dirt in 
house, cellar, alley, backyard, gutter, or cesspool. And the removal of 
these exerted much more influence on the course of the disease than any 
other treatment. 

Clean up, disinfect and keep clean. 



SCARLATIxNA 151 

But while about it, it seems unwise to clean up the environment and 
leave in the patient's alimentary canal the most dangerous of infective 
materials. 

Treat the fever with the Triads. Reinforce the leucocytes by full doses 
of nuclein. 

Wash out the mouth very often with saturated solution of salicylic acid, 
paying special attention to the throat. If this is done early there will be 
some cases of dangerous angina prevented. 

Much discomfort and some danger may be prevented by applying 
petrolatum to the skin every day; or benzoinated lard. This also aids in 
inducing the family to permit free ventilation, for the child will not "take 
cold" when covered with a coat of grease. The diffusion of the scales 
is also thereby prevented. Tepid or warm baths should be given occasion- 
ally. The patient need not be confined to bed if there is little fever, but 
must be kept under surveillance as long as albuminuria continues. 

The best diet consists of milk and fruit juices, with a little coffee, and 
vegetable soups. Jaccoud believes the milk diet aids in preventing 
nephritis. The body should be well flushed by abundance of water. 
Lemonade is useful and agreeable. Buttermilk is sometimes relished 
more than ordinary milk and is more diuretic. Ice-cream is useful for the 
sore throat. 

Hyperpyrexia may demand cold baths, or the McCall Anderson com- 
presses. Ice to the throat is always useful. 

The cold pack may be used in cases where the system is overwhelmed 
by the attack, with full doses of glonoin, atropine and strychnine, adding 
capsicin if necessary. These remedies arouse failing vitality and may 
save an otherwise hopeless case. 

If the throat is well-managed, with salicylic solutions, there is less danger 
of serious angina; but this whole region should be carefully examined 
several times a day. Too often the first intimation the physician has of 
trouble in this part is the bad breath, which indicates that the disease has 
already made dangerous progress. The treatment is that of diphtheria. 

The writer's experience in the epistaxis of scarlatina and diphtheria 
may be concisely stated: Until he began the use of chromic acid every 
patient died; since then every one has recovered. Begin at the first sign 
of bloody discharge. 

If the affection spread to the ears, incise the drum and flush with 
peroxide frequently as recommended above. 

For acute nephritis, keep the kidneys flushed with plenty of water, by 
the stomach, or saline enemas; relax vascular tension by glonoin or veratrine; 
soothe the irritated tissues by benzoic acid, gr. J every two hours; and keep 



152 SCARLATINA 

the bowels easy by glycerin enemas. Pilocarpine may give prompt relief, 
but it may sometimes cause pulmonary edema — and the tendencies to 
dropsy are great. Calcium carbonate, chemically pure, is the most efficient 
of the diuretics, and may be given in full doses with advantage. Quite 
often the stimulant effect of strychnine is required. In fact, this is to be 
given whenever there is any indication of heart- weakness. Many physicians 
have reported favorably on the use of nuclein in scarlatina, and it may be 
given throughout in doses of five to fifteen drops a day, in divided doses, 
dropped on the tongue. 

Can scarlatina be prevented? The writer is one who believes it can; by 
washing the nasal, buccal and pharyngeal mucous membranes several 
times a day with mild antiseptic solutions; saturating with calcium sulphide; 
keeping slightly under the influence of atropine; all these until the danger 
is past and the premises disinfected. There may be a specific influence 
in chlorine — the writer has recommended the simple expedient of gargling 
with salt water to hundreds of persons, and found it successful too uniformly 
to be altogether accidental. When scarlatina is prevalent we see all our 
little clients frequently, and have them take several times a day a mixture 
where free chlorine is generated by the action of hydrochloric acid upon 
dry powdered potassium chlorate (see diphtheria). 

Widowitz says that when urotropin is used from the 3rd week nephritis 
is prevented. Siebert seeks to destroy organisms by applying antiseptic 
ointments to the skin, and lotions to the pharynx. L. Fischer advises 
sodium sulphocarbolate gr. 5 to 20 three times a day — hot salines and 
diuretics liberally, and for the heart sparteine, strophanthus and adrenalin. 

Toussaint begins with the administration of calcium sulphide, two 
granules to adults, one to infants, every half-hour till saturation, then 8 to 
12 a day. If white angina appears give the doses every quarter-hour. 
Rigorous antisepsis of the throat by lemon juice, glycerin of tannin, and 
boric irrigations. Subdue the violent fever by means of the Triads; a 
granule of either combination every half -hour when the fever exceeds 38 Co 
If the eruption does not come out well, add pilocarpine, a granule every 
hour or half -hour till sweating or salivation occurs; then stop, or continue 
less frequently. For the angina, hyoscyamine, a granule gr. 1-268, every 
hour or two, to prevent or correct spasm of the throat. Dysphagia is 
relieved by sucking granules of cocaine like lozenges. See that patients 
drink freely. Give milk, and aromatic, diuretic and diaphoretic infusions. 
Secure intestinal lavage by saline laxative, but avoid diarrhea. Temper- 
ature oscillations and returns call for quinine hydroferrocyanate, a granule 
every half -hour from noon to 6 p. m. even if the fever is then rising. Give no 
solid food while there is any fever; only milk, with one or two oranges a day. 



MEASLES 153 

When the fever has disappeared add light soups, eggs in milk or soft-boiled, 
without bread, and fruit compotes. During desquamation take all care 
against cold, which may then cause renal congestion and nephritis. When 
the urine grows scanty or dark, indicating the admixture of blood, go back 
to the exclusive milk diet, and give infants brucine, digitalin and iron 
arsenate, a granule each three or four times a day; to adults digitalin, 
strychnine and iron arsenates, every four, three or two hours. Let albumi- 
nuria be the guide. For distressing itching apply borated petrolatum or 
mentholated oil, which also prevents diffusion of scales. When desqua- 
mation is complete soap and water will remove debris; put on fresh linen 
and clothes, and disinfect all they have used during the attack. As prophy- 
lactic, when one member of a family is attacked and there are others liable, 
apply antiseptics to the mouth, throat and nose, and gi\£ calcium sulphide 
six to twelve granules a day, to every person liable to the malady. 

MEASLES 

Measles is even more infectious than scarlatina. Second and third 
attacks are not rare, or else there are diseases as yet undifferentiated from 
measles. It may occur at any age, but few escape an attack in childhood 
in the cities. Among the inferior races it is especially virulent. Epidemics 
are more frequent in cold w T eather. It is communicated by the secretions 
from the respiratory mucosa, and may be carried on the clothing. The 
cause is as yet unknown. 

There is no characteristic morbid anatomy. The skin is hyperemic, 
the respiratory mucosa also, and areas of atelectasis are common. The 
bronchial lymphatics participate in the affection. There may be 
hyperemia of the stomach and bowels also. 

Incubation varies from seven to eighteen days; the malady is inoculable, 
and then incubation is less than ten days. 

The attack resembles that of an acute cold — shivering, sneezing, cough, 
redness and running of nose and eyes, intolerance of light, aching of the 
head, back and bones, and great weakness. The stomach is disturbed, 
tongue furred, the soft palate stained as with mulberries. The whole mouth 
except the tongue may show the eruption. Fever rises at once, to 102 or 
more the first day, and 104 or more by the third. 

The eruption appears on the fourth day, on the face, as small flat 
papules, not shotty, spreading downwards over the entire body and extrem- 
ities. The papules enlarge and the whole skin seems swollen. The 
papules are arranged in crescents with unaffected skin between. The 
glands of the neck swell. The rash is most intense on the face. The redness 



154 MEASLES 

momentarily disappears on pressure. The fever does not fall when the 
rash appears but persists till the end of the week, when it drops. Fore- 
running erythemas are not uncommon, and milia and petechia? may accom- 
pany the rash. White or bluish spots with red areolae are to be seen at the 
base of the lower first molars when the mouth is closed. They may be 
found before the rash. 

About the third day of the rash it begins to fade, and desquamation 
occurs in branny scales. Atypic cases are common; some without the rash, 
others without coryza, etc. There is a hemorrhagic form, developing under 
evil hygiene, crowding, low feeding and absence of fresh air. The 
onset is furious and the child may die the first or second day; or petechias 
develop with mucous hemorrhages and ecchymoses, and death before the 
fifth day. • 

The most common complication is catarrhal pneumonia. The fever 
rises and persists, and the symptoms of pulmonary collapse supervene. 
In some epidemics nearly every child is thus affected, and nearly all die 

Laryngitis, edema of the glottis, croup, and stomatitis are less frequent 
than pneumonia. In measles noma, gangrene of the inside of the cheek, 
sometimes occurs, It is insidious in its appearance, and so rare that its 
possibility is apt to be forgotten. Ulcer or diphtheria of the vulva has also 
occurred. The internal ear is often catarrhal, less frequently suppurates. 
The ophthalmia may be purulent. Catarrhs of the bowel are frequent in 
some epidemics. Nephritis is very rare. 

The special danger of convalescence is the development of pulmonary 
tubercle. Arthritis, paralyses, and anchylosis of the jaw are rarely seen. 

The diagnosis from scarlatina is made from the later eruption, the 
mulberry palate, coryza, the eruption appearing on the face, and its crescent 
outline. The spots on the gums are notable. There is no leucocytosis. 
Roetheln does not show the acme of eruption all over the body at the same 
time; in other respects it closely resembles a light form of measles, the 
papules are more shotty, and the influenzal symptoms are wanting, as well 
as the buccal maculae. The backache of smallpox is absent from measles. 
In negroes the presence of influenza is an important means of recognition. 
Drug eruptions rarely have influenza, regular course, or fever. 

Less dangerous than either smallpox or scarlatina, measles is neverthe- 
less to be dreaded in the city slums, in institutions, and in children strumous 
or predisposed to tuberculosis. The danger lies mainly in the respiratory 
complications. 

Treatment: — Put the patient to bed in a well- ventilated but warm room. 
Measles requires warmth as smallpox requires cold. Keep the air moist 
by constant disengagement of steam. This eases the cough. Darkness 



MEASLES 155 

relieves the eyes. Regulate the sick-room hygiene as in other infectious 
fevers. The bowels must be made and kept clear and aseptic. The fever 
may be controlled by the Triads and the cough held in check by emetine, 
gr. 1-67 every hour, or more as needed. Ipecacuanha was believed to 
possess a specific power over the respiratory complications, preventing 
their outbreak and alleviating their violence; but emetine, deprived of the 
irritant emetic cephaeline, gives the same benefits without distressing 
nausea. Give as much as can be taken without nausea. An occasional 
dose of codeine, gr. 1-67, may be given for the cough if the other remedies 
named do not relieve it. 

In an epidemic among the diseased and debilitated foundlings in the 
Philadelphia almshouse it was found that cases showing malignancy were 
markedly benefited by brandy. 

As leucocytosis is absent in measles nuclein should be given from the 
start, in doses of ten or more drops a day, divided. 

For pulmonary involvement, push the emetine, with the Triads 
in doses sufficient to control fever. Veratrine possesses a specific influence 
over pulmonary inflammations; but if the bowels are kept clear and 
aseptic there is little danger of such involvement. 

Cases in which the eruption does not come out and the powers are 
overwhelmed by the intensity of the poison at the onset, require a cold pack 
and powerful vital incitation. Give glonoin, atropine and strychnine 
valerianates, each gr. 1-250 with capsicin gr. i-67,repeated every ten minute- 
till a reaction occurs. The same treatment may be employed for hcmors 
rhagic cases. It is evident that unless the vital forces can be aroused there 
is no hope. 

Wash the mouth out several times daily with mild antiseptic lotions, 
and there will be less danger of noma. Should this occur, burn out the 
gangrene with the hot iron, and apply turpentine; giving internally the 
powerful vital incitants mentioned above, and feeding up to the limit of 
digestive capacity with the richest foods. 

But with good hygiene, aseptic bowels and good nursing, these 
dreadful things do not occur in measles. It is among the ignorant occupants 
of the crowded city slums that measles becomes terrible. 

Toussaint says the leading indication is to combat the infectious 
element. For this calcium sulphide is his chosen remedy, in doses of 
4 to 12 granules a day, according to age. To bring out the eruption he 
adds pilocarpine 5 to 10 granules in two doses three to four hours apart, 
or one granule every hour till sweating begins. Warm drinks may be also 
given but not continued too long. Stop when the rash appears or debility 
will follow. During the whole course of the attack attend rigorously to 



156 MEASLES 

the hygiene of the mouth, throat and nasal passages, using sprays of boric 
acid solution and lotions of boric glycerin. Oppose the fever, which is 
sometimes very high. The Triad if it does not cause the fever to break 
before the usual time for defervescence, will at least moderate it, and by 
holding the organism under the influence of the defervescent alkaloids 
prevent congestion of the lungs. When the eruption is well out and the 
fever subsides, the doses should be farther apart but the Triad 
and sulphide continued, to prevent the bacilli penetrating and 
locating in the lungs. If bronchopneumonia should occur, the treatment 
should be pushed intensively: Put on a cotton jacket; apply sinapisms 
every three hours over the affected lung, or to the back and chest; continue 
the Triad for fever; combat the cough and oppose the proliferation of the 
infectious element by brucine, codeine and calcium sulphide, a granule 
each every half -hour; sustain energetically the forces of the little patient 
with milk, cinchona, grog, with coffee; if needed give brucine and caffeine, 
whole granules or dissolved, at proper intervals during the day; for repeated 
epistaxis, ergotin, quinine hydroferrocyanate, a granule each every quarter- 
hour; for grave cases with urine scanty, red and thick, to induce drinking 
give refreshing tisanes of mallow flowers or cherry stems, even to very 
young babes, keep up to the last day the rigorous antisepsis of mouth, 
throat and nose; keep the bowels free but shun laxatives that may cause 
diarrhea, employing enemas, emollient for constipation, starchy for diarrhea; 
forbid solid food until the complete disappearance of the malady and its 
complications; after the recovery keep the patient indoors for two weeks, 
and from school for another week. The child, its clothes, bedding and the 
sick-room should be disinfected. , 

Toussaint speaks of the mortal complications of measles as noted in a 
two months ' epidemic in his locality. Hundreds of children were attacked 
and many died of bronchial pneumonia. One of his patients died within 
48 hours of suffocative catarrh; two died of convulsions during the eruptive 
period. 

It is known that bronchitis appearing during the course of an infectious 
malady is much more serious than a similar attack due to cold. When 
bronchitis due to cold reaches the smaller bronchi a cure is the result; 
that occurring during whooping-cough is graver, but here also there are 
more cures than death. When influenza or measles is complicated with 
bronchial pneumonia the prognosis varies widely according to the epidemic; 
some furnishing a mortality truly frightful for young infants (Veillard). 

Calcium sulphide, administered in intensive doses from the onset of the 
first attack, should be continued throughout as the basis of medication, 
while the inflammation itself is combated by defervescent alkaloids added on 



MEASLES 157 

occasion by baths, compresses cold or warm, sinapisms, dry cups, etc. He 
thinks with Veillard that one should abstain from blisters in infectious 
maladies. They depress the little patient and are often the point of 
departure of ulcerations very difficult to cure. 

Suffocative catarrh is nothing else but a capillary bronchitis generalized. 
The fever is violent; rales sibilant, bubbling, sonorous, are diffused over 
both sides of the chest; oppression increases every minute. 

If there is time we apply daily cups in great number or envelope the 
thorax in vast mustard poultices; or we put the infant in a mustard bath. 
If the child can swallow we frequently give with success an emetic, 
which temporarily free the bronchioles. The infantile Triad (brucine, 
aconitine and digitalin) is then given in suitable doses to reestablish the 
circulation in the engorged lungs. But too often the physician is called 
when the life of the little patient is already compromised and he cannot 
prevent asphyxia accomplishing its work. This was the case with the first 
child mentioned as dying. It had been seized the preceding evening with 
measles, the third attack in the family within 10 days. The other two were 
better. The eruption came out badly, the lungs became inflamed, the 
condition was aggravated, and when the doctor was called on the second 
day he found the child suffocating. 

The other two died in convulsions. They were very strong and well- 
developed, but exceedingly nervous. The first had played for six days 
in the room with his little morbillous brother. January 2 1st he commenced 
to sneeze and cough, the eruption appearing next day. At 2 p. m. after 
some grimaces and nervous movements he entered the crisis. At first partial 
and affecting a part of the face, arm and leg, the spasms quickly assumed 
the chronic form and left him not a moment of repose during 10 consecutive 
hours. Hot baths, mustard baths, flagellation with towels dipped in cold 
water, ether by inhalation and internally, chloral enemas, were all tried. 
Overcome by a conflict which would have strained a giant, the little patient 
died without regaining consciousness. The second child died in identical 
fashion. A chloral enema seemed for a time to suspend the spasms, but 
they returned more severely and the child died without regaining con- 
sciousness, after eight hours of the most horrible torture. 

Possibly chloroform inhalations and morphine injections as proposed 
by Le Grix, might have done better. 

We cannot but look upon this record as a further illustration of the 
limitations of French Dosimetrists. In this terrible emergency they desert 
the well-tried remedies of their own advocacy, and have recourse to the 
inefficient methods and weapons of the older practice. We feel confident 
that in active, well-chosen applications of such remedies as pilocarpine, 



158 RCETHELN 

atropine, morphine and colocynthin, better results could be obtained. 
Eclampsia is autotoxemia, and pilocarpine most quickly relieves conditions 
due to the retention of waste products in the body. Before its tremendous 
power, its prompt action in unlocking the gates of elimination, how paltry 
appear the weak and ineffective measures instituted by our colleague. 

RGETHELN 

Under numerous titles, German measles, French measles, rubeola, 
roseola, rubella, scarlet rash, a fourth member of the exanthemashas been 
recognized in comparatively recent times. It was thought to be a hybrid 
of measles and scarlatina for some time, but is now acknowledged as a 
distinct disease. It is as contagious as measles, and like it occurs in 
epidemics. 

The symptoms are quite similar to those of measles but milder. The 
incubation lasts ten days or more. The invasion shows chilliness, aching 
in the head, back and legs, coryza, a macular rosy eruption on the soft 
palate, a little fever, and on the first, second or third day a rash, first on 
the face and spreading downward, covering the whole body within 24 hours. 
It resembles measles but is brighter and less crescentic. It begins to fade 
first in the face, reaching its acme there before it does in the extremities. 
The cervical glands are swollen and sore. Other lymphatic glands also swell. 
Albuminuria and nephritis are more frequent than in measles. Pneumonia, 
jaundice and colitis are occasionally seen. Sometimes this malady becomes 
as severe as bad forms of measles, but is usually very similar but milder 
in the whole range of its symptoms. - 

The treatment is that of measles. 

WHOOPING-COUGH 

The writer believes this to be the most contagious of all diseases. His 
own children took it while passing several yards from an infected child on a 
steamer. It probably depends on a bacillus found by Koplik — small, 
with rounded ends, somewhat larger than the influenza bacillus. It is to 
be found in the mucous clumps; is a facultative anaerobe, pathogenic for 
mice. Epidemics are frequent in the cooler months and often precede 
the exanthemata. It occurs more frequently among children, even in early 
infancy; they are immune. It affects the aged sometimes, dangerously; 
it is self -protective; it is especially fatal to negroes, and in London is one of 
the chief causes of children 's death. 

There is no special anatomy. Respiratory affections are the causes of 
death. 



WHOOPING-COUGH 159 

The incubation lasts seven to ten days, with no symptoms. The catarrhal 
stage commences with coryza, slight fever, red eyes, dry cough, in no way 
distinguishable from an ordinary cold. Suspicion is not, as a rule, aroused 
until about the time an ordinary cold would be breaking up, when this begins 
to display its spasmodic character, the cough becoming dryer and more 
troublesome. Three things arouse suspicion before the whoop begins: 
The cough occurs in paroxysms; they awake the child from sleep; and he 
coughs till he vomits. Then comes the distinctive cough, with a number 
of spasmodic expiratory efforts, followed by a long-drawn crow or whoop, 
drawing the air through the contracted glottis. He gets red in the face, 
his nose may bleed, and points of blood be forced out on his temples from 
the violence of the straining. From 20 to 24 paroxysms occur each 24 
hours. The efforts continue until a mass of tough adhesive phlegm is 
ejected, much or little. The face is swollen and the eyes protrude, the 
countenance cyanotic. Children run to their parents for support when the 
paroxysm comes on. The attacks may be induced by temper or any 
emotion. Sometimes the vomiting is so constant that the child suffers 
from innutrition. 

The duration of an attack is not uniform. The laity say it runs up 
nine weeks and down the same period; but it may be shortened, and, again, 
habit may indefinitely prolong it. 

Hemorrhagic effusions may occur about the temples, the eyes, or from 
the respiratory mucosa. 

Convulsions are rather common in bad cases. Paralysis rarely ensues. 
Sudden death has followed bleeding under the dura. Emphysema, 
pneumothorax, catarrhal pneumonia, lobar pneumonia, pleurisy, hypertro- 
phy of the bronchial glands, valvular disease, albuminuria and glyc- 
osuria are among the complications and sequels. Leucocytosis occurs 
early. 

The whoop is not distinctive, since it occurs with other laryngeal 
affections. The three symptoms mentioned, followed by the whoop, are 
characteristic. 

Whooping-cough is especially dangerous to very young and to feeble 
children. 

Affected children must be isolated and kept from the schools until the 
danger of contagion is past. The treatment is quite satisfactory. Many 
claim that the malady can be jugulated by keeping the patient saturated 
with calcium sulphide and slightly under the influence of atropine. Give 
of the former a grain every hour till the breath and skin smell of the drug; 
then enough to keep up this effect. Give atropine gr. 1-500 every hour, 
or a corresponding dose suited to the age, until the child speaks of dryness 



160 WHOOPING-COUGH 

of the mouth or the skin becomes reddened; then continue enough to keep 
up this effect. Many cases have been reported in which this treatment 
was given to unprotected children exposed to the infection who had shown 
no signs of an attack, and have in subsequent epidemics proved immune. 
It is believed that they had taken the infection, but it was destroyed by 
the sulphide in the incubative period. 

Many other methods have been employed and some have given good 
results, such as that of full doses of quinine — gr. 3 to 4 for a child of 2 years 
old, every four hours — but none has done as well as that described. Fumi- 
gating the bedroom and clothes with, burning sulphur has been lauded. 
Local applications of various antiseptics are used. It is probable that the 
quinine acts in this way, since it is best when given in syrup of yerba santa 
and not in pills. 

Toussaint thus summarizes the treatment of the French dosimetrists: 
Calcium sulphide forms the dominant. It may be given with success as 
a preventive in an epidemic, in doses of 8 to 12 granules a day, according 
to age. Make the toilet of the mouth and nasal passages many times 
a day, also, to prevent the access of the microorganisms. 

Saturate the patient with sulphide and keep up the influence of this 
parasiticide. During the catarrhal period soothe the cough with codeine, 
iodoform, helenine, a granule each at each paroxysm. Prevent viscous 
accumulations in the bronchi with emetine and codeine, scillitin, and in 
certain cases pilocarpine; some doses of each in the morning. N Repeat 
in the evening if the paroxysms are not followed by free expectoration. 
During the spasmodic period give atropine valerianate, a granule every 
two to four hours, according to age. For very young infants this granule 
should be dissolved in four to six teaspoonfuls of sweetened water or black 
coffee, and a teaspoonful given every half-hour. Combat the intermittence 
and recurrence of paroxysms with quinine hydroferrocyanate, one to 
four granules. Sustain the heart, if enfeebled, with brucine and digitalin, 
a granule each every half hour till better. For epistaxis with paroxysms 
give ergotin and quinine hydroferrocyanate, one to four granules. For 
vomiting give morphine, brucine or strychnine and hyoscyamine. Watch 
the bronchi, as fatal complications may arise here. At the first indication 
apply sinapisms and give the infantile Triad until the temperature returns 
to normal. If the paroxysms are very frequent at night give narceine, 
codeine, butyl-chloral, a granule each at bedtime. Sustain the vitality 
with brucine, iron phosphate, strychnine, lime and soda hypophosphites, 
one to four granules each, daily. For anorexia give brucine and quassin, 
one granule each before meals. In happy cases two granules of calcium 
sulphide and one of camphor monobromide every hour suffice to cure 



WHOOPING-COUGH 161 

in some weeks. Boucher cured one case, a babe of 9 months, in eight 
days. 

Le Grix quotes a non-dosimetric friend who tried calcium sulphide, 
with camphor monobromide, in whooping-cough. His report was that — 
"No other treatment up to the present has given me effects so precise, 
so remarkable, especially in four cases. In the others the treatment, 
ill-followed, appeared to notably modify the course of the affection." 

Salivas employed the same combination in a severe case, with good 
results, even with smaller doses. A man aged 5 1 was seized with a terrible 
attack, resisting treatment by drosera, aconite, morphine, chloral and 
bromides. After two months of suffering he was placed on the above 
combination, with morphine. The results were satisfactory. 

Frank said that one* might cause the patient attacked with whooping- 
cough to die before the end of the attack, but cure it — never! Salivas 
says that we attack the pathogenic agency at that same time that we 
sustain the vitality of the patient, this constituting the dominant treatment. 
For this purpose, after having cleared the respiratory passages of obstruc- 
tion by an emetic, three granules of emetine, gr. 1-67 each, every ten 
minutes till effect, we administer calcium sulphide, a granule gr. 1-6 
every half hour at first, later every hour; with brucine three to six granules, 
each gr. 1-67, per diem, separately from the sulphide. 

If the paroxysms assume the characteristic type we combat the spas- 
modic element by adding to the above camphor monobromide, a granule 
with each dose of sulphide, and atropine valerianate a quarter, half or 
whole granule, according to the age of the patient, every three or four 
hours. This completes the dominant treatment. 

The variants are directed against the complications. 

If measles appears we care for it without suspending medication 
directed against whooping-cough. 

If engorgement of the lungs supervenes, capillary bronchitis, we make, 
without loss of time, mustard applications to the back and chest, and 
prescribe the Dosimetric Triad. 

Ulcers of the lingual frenum, so common in whooping-cough, are to 
be cauterized with silver nitrate, or many times touched with boroglyceride. 

During the paroxysms watch the patient closely and hold the head 
inclined forward to facilitate the expulsion of encumbering mucus. If 
syncope occurs, nevertheless, it is necessary to have recourse to revulsives, 
Mayor's hammer, artificial respiration, rhythmic tractions of the tongue. 

For the innutrition due to repeated vomiting of food make the patient 
eat after the paroxysm, giving but little food each time, but multiplying 
the meals. 



i6 2 WHOOPING-COUGH 

During the third period change of air and tonics are indicated to 
prevent relapses. Isolate patients, quarantine houses and disinfect. 

The dominant treatment is filled by calcium sulphide, in high doses 
and regularly, to preserve for some time the constant action upon the 
body of an interior atmosphere of sulphydric acid. As a variant against 
the nervous element give codeine or camphor monobromide. 

According to age, ease of swallowing and toleration, we give two to 
five granules of calcium sulphide every two hours, or more frequently, 
when the first spasmodic paroxysms occur; or even in the catarrhal period 
if significant circumstances allow us to foresee the later development of 
spasmodic catarrh. 

At the outbreak we may hope for jugulation by active and very regular 
treatment. Injurious effects of the sulphide need not be feared, for there 
are none; some nausea caused by the bad odor, some belching, and that is 
all. Infants take the granules easily, if large enough, and accustomed to 
dosimetric treatment. The following case is described: 

October 18 a girl of ten years, strong and robust, sanguine but very 
poor, was attacked with whooping-cough and the patient first seen during 
the second stage. She had already taken, without success, quinine, 
chloral and codeine. 

TreBtment: — A general lukewarm bath; calomel and antithermin; 
regular diet, as nutritious as possible, meat and wine. She was confined 
to one room with phenol evaporating constantly. Calcium sulphide, 
a granule every half hour; codeine, a granule every hour. During the 
day exercise in the open air in the garden. 

At the end of two days the patient was evidently improved. The 
paroxysms had lessened from 30 to 8 per diem, the vomiting had ceased; 
the nights were tranquil, with some hours' sleep. During ten days the 
improvement was constant and progressive, and as the cough improved 
the general condition of the patient advanced equally. Twelve days 
after the first visit she was cured, having only a little, soft cough. The 
appetite was excellent, she digested well, and all other functions were per- 
formed normally. 

Many physicians believe that whooping-cough pursues a regular and 
unvarying course, with which treatment will not interfere. This view is 
the cause of many ills. That whooping-cough is a grave and often mortal 
malady by itself, or with its complications, leaving after it more or less 
enduring consequences, no physician today will deny. But we maintain 
strongly today that it is the negation of aid from the art of medicine, 
which plays the most important part in the want of success and the sad 
and lamentable accidents with which this malady is accused; for, like 



WHOOPING-COUGH 163 

all other maladies of the human body, this one is susceptible of treatment 
and of cure; and if treated with intelligence the cure obtained is more 
complete and sure than that which nature affords. 

We do not deny that there are unfounded enthusiasms prevalent con- 
cerning the art of curing, but we love, without reserve, to render justice 
to the power of medicine. It is the want of a reasonable confidence in 
its power which has caused our art to lose its prestige, its opportunity and 
its force. 

Laura thus treated severe whooping-cough: The room should be 
large, well aired, kept at a uniform temperature; in fine weather the 
child may spend the day in the open air; clothe in light wool; avoid 
fatigue, emotion, night-air, immoderate laughing or crying; feed care- 
fully easily digestible nutritious food; the basis milk, soups, chocolate, 
meat, eggs, somatose, peptones. If the child vomits its food, give more. 
Medicate by indications; secure sleep; for fever, aconitine, quinine, 
hydropathy; for the spasmodic element, hyoscyamine, codeine, atropine, 
croton chloral, camphor monobromide, iodoform, singly or combined. 
Helenine merits a place, from its action disinfectant, antimicrobian, tonic 
expectorant; it restores the digestion and sustains the nervomuscular 
action of the stomach. Intubation or tubage may be required. 

Quinine, by its power anti-infective, sedative and tonic, is a remedy of 
the first rank. Calcium sulphide is the antimicrobian for older children. 
Applications of cocaine and resorcin are useful. Inhalations, sodic, 
bromic, of eucalyptus, chamomile, or terebinthinate, are excellent adju- 
vants. 

In the late catarrh the balsams, emetine, kermes, terpine. For cardiac 
debility, digitalin, caffeine, strychnine. For gastric debility, gastro- 
nervous modifiers. Diligent asepsis of the nose, mouth and throat. 

For the frequent anemia, iron, arsenic, glycerophosphates; perfect 
feeding and the climatic cure. 

Berchon describes a case of whooping-cough occurring in a boy of 
five years. He had been eight days ill. Four days later he presented 
the characteristic paroxysms, which were frequent, with some fever and 
no vomiting. He was placed upon calcium sulphide, a granule every 
hour, following five granules of emetine, given to clear the respiratory 
tract. Camphor monobromide, a granule every hour, was added for the 
spasmodic element. 

The paroxysms became more frequent, reaching 20 within 24 hours, 
although shorter in duration. The two remedies above named were 
ordered then every half hour, with atropine valerianate, a granule every 
four hours. 



i6 4 WHOOPING-COUGH 

The number of paroxysms diminished to 15 each 24 hours, with two 
vomiting spells, the general condition being good. An increase in symp- 
toms attended constipation, and movement followed immediately after 
the action of a saline laxative. Nevertheless, the treatment embraced 
a period of 29 days, making the total duration of the malady 37 days. 

This is by no means such a result as Coleman had obtained. The 
remedies do not seem to have been pushed to their full effect and the 
alimentary canal was certainly neglected. The most important observa- 
tion in this case, however, was that a brother of the sick child, aged three 
years, remained with him during the entire course of sickness, taking 
6 grains of calcium sulphide a day, and did not contract the malady. To 
one who realizes the certainty with which a person liable to whooping- 
cough will contract it under these circumstances, this being the most infec- 
tious of all known diseases, this observation is entirely significant, especially 
since it has been confirmed in numerous instances by Coleman and others. 

Kortz relates a case of pseudo-whooping-cough. The patient was a 
boy, aged three years, thin and delicate, disposed to rickets. For some 
days he had paroxysms of cough, worse at night, no fever, appetite about 
as usual, five or six paroxysms occurring each night. The submaxillary 
glands were swollen, the chest full of the large, moist rales of bronchitis; 
cough syrups did no good and emetics were inadvisable, as he vomited 
much at the paroxysms. Percussion furnished no evidence. The parox- 
ysm of cough at the outset resembled that of whooping-cough,, but was 
aborted in about ten seconds. 

This appeared to be not true whooping-cough, but a heavy cold in 
a lymphatic child, with exaggerated ganglionic development. 

Sinapisms were applied twice a day to the back and chest; one granule 
of calcium sulphide ordered every hour; one granule of camphor mono- 
bromide every two hours to oppose the nervous element; to combat the 
lymphatism sodium arsenate gr. 1-67 before meals, daily. 

In four days there was evident amelioration, the lungs relieved of 
rales and the paroxysms less frequent and shorter, vomiting less frequent. 
Treatment continued, except the sinapisms, and the arsenate given three 
times a day, the daily dose being gr. 1-67. Four days later the bronchi 
were free, the paroxysms like the preceding but further apart and briefer, 
while the child's general appearance was improved. The same remedies 
were continued less frequently, and during convalescence calcium phos- 
phate added for the rickety tendency. 

The hopeful and confident tone of these reports is notable. 

Coleman claims it is possible to make a diagnosis of whooping-cough 
within the first three days of the catarrhal stage. He calls attention to 



MUMPS 165 

the broken, quick, expiratory spasmodic cough, in patients known to 
have been exposed and non-immune; a small tumor under the tongue 
at the root of the frenum, the size of a split pea; hypertrophy of the tracheo- 
bronchial glands; and a string of hypertrophied glands running from 
the angle of the lower jaw to the sterno-clavicular articulation. 

Illoway calls attention to a prodromal sign, in a slight hacking cough 
occurring a few times during the day and later at night without disturb- 
ing the sleep. This may precede whooping by four weeks. The longer 
it lasts, the more severe the attack will be . 

MUMPS 

While mumps is an infectious malady its cause is as yet undetermined. 
It is most frequent in children, in the spring and fall. It is highly con- 
tagious, and getting into a school will affect every child except the few 
who seem to be immune. After the twenty-first year it is rare. 

The incubation lasts two to three weeks, with no symptoms. The 
attack is marked by slight fever, with pain in the parotid gland on one 
side. This soon swells and becomes tender. The other side may or 
may not "be affected. Sometimes the submaxillary and sublingual glands 
are involved. It becomes difficult to open the mouth and impossible 
to chew. Any food that excites saliva causes acute pain. A cruel domes- 
tic means of diagnosis is to induce the patient to take a bite of pickle; 
which causes exquisite suffering. The pain may radiate to the ears 
and otitis develop. In about a week the malady subsides, taking longer 
if the second gland is not affected till late. Sometimes there is metastasis 
to testes or ovaries, but only in persons past puberty. Great suffering 
ensues; the attack runs its course there and subsides. There may be a 
urethral discharge of pus. One or both sides may be affected. Atrophy 
may result, with impotence if on both sides. Girls may have vulvo- 
vaginitis, and the breasts in either sex may swell and become sore. 

High fever with delirium occasionally occur; meningitis rarely; hemi- 
plegia, coma, mania, arthritis, albuminuria, uremia, endocarditis, facial 
paralysis and metritis, are sometimes seen. Very rarely the parotid 
suppurates. Deafness is not unusual. The eye may be injured; the 
nerve atrophying. Relapses may occur. The gland may remain enlarged. 
A long list to follow mumps, but they are collected industriously, as men 
in active practice for a lifetime may not see one of them. 

The diagnosis is easy; the parotid swelling, with aggravation of the 
pain on taking into the mouth anything sapid; occurring in persons who 
have been exposed and are not immune. 



166 MUMPS 

Treatment: — Keep the child quiet, clear out the bowels and give a 
few granules of aconitine. Possibly pilocarpine may abort this malady — 
try it in full doses. Cover the swollen glands with belladonna plaster. 
Metastasis calls for the use of hot or cold applications as may be most 
agreeable. During the writer's absence from home his son, aged n, 
showed symptoms of mumps. He had never had this disease and had 
been fully exposed. His mother at once gave him enough atropine to 
dry his mouth, and saturated him with calcium sulphide. Within two 
days the attack was broken up, and he subsequently associated with chil- 
dren affected with mumps, with entire impunity. 

Toussaint speaks of a characteristic symptom. If the finger is intro- 
duced into the patient's mouth the finger remains dry, saliva being absent. 
In grave cases the ordinary expectant treatment becomes a serious fault. 
The treatment should be that of infectious maladies in general, the prin- 
cipal indication being met by calcium sulphide, which should be given 
during the entire course of the disease and some time longer to prevent 
relapses. The daily dose is the same as for measles or scarlet fever, i or 2 
granules every half hour, according to the age, until saturation; then 
12 to 16 every 24 hours. 

The fever should be moderated by suitable doses of the infantile Triad 
(brucine, digitalin and aconitine), continued until the temperature falls 
to 37 1-2 degrees C, and after that according to the need. 

The swollen glands should -be covered with absorbent cotton impreg- 
nated with oil of chamomile, containing camphor and morphine and 
covered with silk. 

A careful toilet of the mouth and throat should be made two or three 
times a day, with a solution of boric acid. This is indispensable. 

Orchitis, mammitis and ovaritis are treated by applications of hot 
opiated oil, cataplasms or better "cottonplasms;" or if suppuration is 
feared, by mercurial inunctions. 

Fever is attacked by the infantile Triad if the patients are under 6 years 
of age. 

For the saburral condition give small daily doses of saline laxative. 

For vomiting give soda lemonade, or champagne. 

The dieting is very difficult. It should be exclusively liquid — soup, 
milk, beef and chicken tea, etc. 

Patients should be isolated and those exposed to contagion should 
take calcium sulphide, 8 to 12 granules a day as a prophylactic for 20 to 
25 days. When the patient has recovered, the house should be disin- 
fected and all playthings and other substances which have been used about 
the patient's mouth should be burned. 



PNEUMONIA 167 

This description leaves much to be desired. Of profound interest is 
the effect which pilocarpine would have in this malady in minute doses 
and when pushed to full effect. The treatment for metastasis is also 
unsatisfactory and the effect of atropine here deserves careful study. 

PNEUMONIA 

A specific fever caused by the invasion of the lung by the pneumo- 
coccus, or micrococcus lanceolatus. The disease affects one or more 
lobes, in one or both lungs, commencing at the apex of each lobe and 
extending toward the pleural surface, with variable rapidity. There are 
three stages. 

hyperemia: — The tissue is dark-red, firm, heavy, but floats in water, 
the air-cells distended, and if any lobules are collapsed they can be inflated 
by the bronchus. Extravasation may occur near the pleural surface. 
The epithelium is swollen, capillaries engorged, air-cells and bronchioles 
filled with epithelium, red cells and some leucocytes. 

Red hepatization: — The lung is solid, airless; liver-like, mahogany 
color, dry, mottled, swollen, too heavy to float, not inflatable, friable, 
the air-cells and bronchioles filled with fibrinous plugs that give the cut 
surface a granular appearance. The pleural surface is covered with 
fibrin. The fibrinous plugs contain red, pus, and epithelial cells. The 
connective tissue is sometimes filled with leucocytes and fibrils, the vessels 
are pervious and pneumococci are to be found — sometimes streptococci 
and staphylococci. 

Gray hepatization: — As the exudate becomes fatty the color pales, 
the tissue softens, the exudate liquefies, and numerous leucocytes invade 
the air-cells. Resolution sets in and the exudate is largely removed by 
the lymphatics. But the attack may not terminate so favorably. Suppura- 
tion may occur, pus cells infiltrating the tissues and air-cells, possibly 
ending in abscess from streptococcal conquest of the enfeebled tissues. 
The abscess may discharge or caseate. (See Pulmonary Abscess.) Gan- 
grene is a rare ending. Induration sometimes ensues, the alveoli filled 
with new connective tissue. 

The heart-muscle is pale, the blood highly coagulable; pericarditis, 
endocarditis, desquamative and intestinal nephritis, and rarely meningitis, 
may complicate. The spleen is congested, the stomach and bowels 
catarrhal. 

Etiology: — The pneumococcus of Frankel is lance-shaped, occurs in 
pairs, is often found in the nose and mouth of healthy persons and espe- 
cially in those who have had pneumonia. It may be demonstrated in 



168 PNEUMONIA 

the sputa by treating a cover-slip preparation with glacial acetic acid, 
washing off the acid, and adding anilin oil and gentian violet, poured 
off and renewed several times. Other organisms are found in the sputa, 
such as Friedlaender's and Eberth's bacilli, influenza bacilli, streptococci, 
etc., and it is probable that they also cause the disease we term pneumonia, 
alone or with the pneumococcus. 

Palier asserts that the ordinarily harmless diplococcus of the mouth, 
gaining access to the mouse, there develops the virulence that enables it 
to arouse pneumonia when transferred back to the human respiratory 
tract. Birchmore believes there are at least three forms of pneumonic 
infection, the most fatal being that attacking travelers, with insidious 
attack. 

Infection occurs by inhalation of the causal microorganisms, the 
pneumococcus perhaps opening the way for the others. Predisposing 
causes are, i, endemic influence, certain buildings becoming infected; 2, 
epidemic influence, and direct contagion; 3, season, the cold and wet 
of winter; 4, exposure to cold, lowering the vitality of the tissues to a 
point when the ever-present pneumococcus can successfully attack them; 
5, age, the extremes of life being most liable; 6, sex, whose only influence 
is as to relative exposure, males being most frequently attacked; 7, bad 
hygiene, the crowded city slums showing the most and worst cases; 8, 
alcoholism; 9, typhoid, measles and other septic fevers are sometimes 
complicated with pneumonia; 10, it occurs as a terminal malady to finish 
off sufferers in the last stages of chronic nephritis, diabetes, cancer, heart- 
disease, etc. 

Climate has some influence on pneumonia, it being somewhat more 
fatal in the south, where the vital resistance is less than in those who have 
been toughened by exposure to the northern winters. But in every part 
of our country, north and south, in the hot moist air of Florida and the 
thin dry atmosphere of the Rockies, the bleak barrens of Canada and the 
rich jungles of the Mexican coast, pneumonia prevails as one of the prin- 
cipal causes of death. The causal agencies are omnipresent. One 
attack predisposes to another, and this is easily comprehended when we 
find the pneumococcus a life-long guest in the mouth, ready at any time 
to attack its host again, when his vitality is low. 

Pasteur found it impossible to inoculate the cock successfully with 
the pneumococcus, that bird's normal temperature being higher than 
man's. But when he was placed in a refrigerator till his temperature 
fell to 98 F., the pneumonic infection took place. This throws light on 
the attacks following exposure to cold, especially when the vital resistance 
is paralyzed and the body heat reduced by alcohol. 



PNEUMONIA 169 

The serum from the blood of convalescents contains an antitoxin 
which cuts short the disease in others, inducing crisis. The pneumo- 
coccus generates pneumotoxin, which causes fever; and acting on the 
body-albumin generates an anti-pneumotoxin, which neutralizes the 
toxin in the blood as it is formed. It has not yet been isolated. 

Symptoms: — Sometimes when one has " taken cold" from exposure 
there are several days of malaise, illness without demonstrable disease 
of the lung. The patient knows he has contracted a malady, but appar- 
ently it has not yet established itself at any one locality. In such cases 
it is probable that a slight pneumococcus invasion has taken place at the 
apex of one lobe, the microorganisms being so few in number that repeated 
hatchings of new broods are necessary before they can produce typical 
symptoms. Meanwhile the infection is spreading slowly up the lobe, 
and in due time the identity of the disease is established. 

In other cases the attack opens abruptly with a chill, followed by 
fever up to 104 degrees, oppression of the chest, substernal soreness, 
rapid pulse, the skin hot and dry, the cheek on the affected side showing 
a curious red flush, headache, weakness, anorexia, thirst, very often 
delirium. Deep inspirations do not cause acute stitching pain until the 
disease has spread through the entire lobe to the pleura. Respirations 
are hurried and shallow, 30 or more per minute. Cough is irritative, 
dry, painful, the sputa at first scanty, gray and sticky, soon becoming 
rusty, and stained with bright blood when collateral hyperemia develops. 
Little. children have a peculiar catch in the breathing, just before expira- 
tion, which is quite characteristic. There may be gastrointestinal catarrh, 
at first or at any time later, with anorexia, nausea, vomiting or diarrhea. 
If marked, this is a dangerous element. 

The patient lies on the affected side, mouth open, lips stained, eyes bright, 
speech restrained by the painful and rapid breathing. In alcoholics the 
delirium may simulate delirium tremens. An eruption of herpes often 
appears about the nose or lips. The fever rises as night approaches, the 
daily range being about one degree. The pulse runs to 100, being slow in 
comparison with the fever. 

The malady continues in this manner until the fifth, seventh or ninth 
day, when in favorable cases crisis occurs, with a sudden fall of temperature 
below normal, profuse sweating or diarrhea, great, sometimes fatal prostra- 
tion, and relief from the dyspnea, cough and other distress. Convalescence 
goes on rapidly, but the evidences of consolidation may be detected for 
weeks after the crisis. 

In other cases crisis does not occur, but purulent infiltration supervenes, 
the symptoms decline by lysis, convalescence is protracted, and the patient 



170 PNEUMONIA 

recovers with more or less damage to the lung; perhaps none, perhaps some 
fibrosis or atrophy. 

Respiration: — The patient breathes from 24 to 60, children 90 or more, 
times per minute. He pants, restrains the thoracic movement, and suffers 
dyspnea in proportion to the fever. When several lobes are affected the 
collateral fluxion in the remainder renders the oppression almost unbearable. 
Bronchial catarrh coexists to some extent. The rate of the respiration to 
the pulse is 1 to 1.5 or 2, instead of 1 to 4 as in health. The pain develops 
with pleural involvement, in several hours or more, and lasts three days. 
It is made worse by coughing. The cough is dry, harsh and constant, 
repressed after pleurisy develops, but may be much less annoying in the 
aged, in alcoholics and when delirium is marked. 

The sputa are at first gray and adhesive, becoming blood-stained or 
rusty in a few hours, and mucopurulent, abundant and thinner at the 
crisis. In aged and prostrate subjects they resemble prune-juice. If 
collateral fluxion is marked it is frothy and bright bloody; if edema develops 
it becomes serous. Aged patients are apt to swallow it and have to be 
compelled to cough up "from the bottom of the lungs" to obtain enough for 
inspection. Red cells, pus cells, epithelium, fibrin casts and the pneumo- 
coccus, may be found by the microscope. 

Fever; — The temperature rapidly rises to 104 or more, fluctuates a 
degree daily, and drops rapidly to below normal at crisis. Children may 
have an initial convulsion instead of a chill. Aged and weakly persons 
may have lower fever. An attempt at crisis (pseudo-crisis) may precede 
the true crisis a day or more. Hyperpyrexia, 105 to 107 , may precede crisis, 
which is more apt to come by night. Febrile rises may occur during con- 
valescence, from slight causes, such as an unpleasant visitor, too heavy a 
meal, etc. Failure of crisis to appear on time may indicate a complication, 
or purulent infiltration. 

Circulation', — The pulse runs about 100 and if above 120 indicates 
danger, as threatened heart-failure. This is due to the fever, to the increased 
task of the heart in driving the blood through the lessened number of 
capillaries in the non-pneumonic lobes, themselves engorged by the collateral 
hyperemia, and to the decreased nutrition of the heart from the abstraction 
of fibrin from the blood and from the interference with nutrition. Peri- 
carditis sometimes occurs, and this, or previously existent heart-disease, 
increases the danger. A small rapid pulse, with irregularity and dicrotism, 
betoken danger. If full and abounding the tension is low. Increased 
tension in the pulmonary vessels accentuates the pulmonary sound 
(second sound, heard in the left second intercostal space, an inch from 
the sternum). If the right ventricle weakens dilatation results. 



PNEUMONIA 171 

Leucocytosis is marked, continuing until the true crisis. Polynuclcar 
forms of white cells prevail during fever, diminishing as the eosinophils 
multiply. The red cells and hemoglobin decrease rapidly after the crisis. 
The blood-plates increase. 

Nervous System: — Headacne occurs at the start and may persist. 
Convulsions may be present in children. Delirium is common. If the 
fever is high it is of maniacal type, while in septic states it is low, muttering, 
with a tendency to coma. Drunkards exhibit typical mania a potu. When 
fever rules very high the symptoms may simulate meningitis. 

Skin: — Herpes of the nose or lips is of some importance in diagnosis. 
Profuse sweats mark the crisis. The well-defined flush on the cheek of the 
affected side has been noted. Urticaria occurs sometimes. 

Digestive System: — The tongue is dry and brown in high fever and 
great debility, covered with a uniformly yellowish-white coating 
ordinarily. Marked vomiting or diarrhea may indicate infection of the 
alimentary canal, and such cases are apt to prove fatal. The spleen is 
enlarged, not the liver. 

The Urine: — The urine is scanty, red, of high specific gravity, urea and 
uric acid in excess, chlorides deficient. Some albumin is often to be found. 

Physical Signs: — First stage: Expansion lessened; costo-abdominal 
breathing in double pneumonia; tactile fremitus slightly increased; per- 
cussion normal or briefer, higher pitched or tympanitic; crepitant rales, 
vesicular sounds weak over affected lobe, exaggerated over healthy lobes. 

Second stage: Little expansion over affected side, increased on side 
unaffected; vocal fremitus increased usually, friction sounds often; percus- 
sion dullness over affected lobes posteriorly, tympanitic anteriorly, Skoda 's 
resonance above affected lobe; bronchial breathing, bronchophony, some- 
times egophony, subcrepitant rales from bronchitis, friction from pleurisy. 

Third stage: Expansion returning, fremitus lessening, dullness slowly 
disappearing, crepitant rale redux, coarser than in the first stage as the 
exudate is softening; bronchial breathing, gradually replaced by vesicular 
sounds. 

Complications: — Pleurisy, usually fibrinous, is always present when the 
pneumonia reaches the pleura. If the pleuritic symptoms are prominent 
the malady is termed pleuropneumonia. Empyema may supervene. 
Acute bronchitis may coexist. Collateral fluxion may occasion edema, 
the dyspnea reaching its highest point and the patient dying if not promptly 
relieved. Pericarditis may result from extension in left pneumonias. It 
is more frequent in children. Endocarditis is more frequent, especially 
the ulcerative form; betoken by septic fevers, chills and sweating, with 
embolism and meningitis. It is due to infection of the endocardium by the 



172 PNEUMONIA 

pneumococcus. Heart-clot, venous tnrombosis and arterial embolism 
occur rarely. Acute suppurative meningitis is rare but grave; with intense 
headache, stiff neck, wild delirium, gradually subsiding in coma. Peripheral 
neuritis, parotitis, real rheumatism and pneumococcal arthritis have been 
noted. Croupous gastritis is rare, croupous colitis more common. Jaun- 
dice is frequent in severe forms. Peritonitis is rare, as in acute nephritis 
of a mild grade. 

Varieties: — Typhoid pneumonia is characterized by the typhoid state, 
profound prostration, low delirium, stupor or coma vigil, heart feeble, 
tongue brown, fever moderate, skin dusky or yellowish. 

Epidemic pneumonia is often malignant. In " larval pneumonia" 
the general symptoms are mild, the signs obscure. 

Latent pneumonias begin at the lobar apex and never reach the pleura. 
In emphysematous subjects the signs may be masked. 

Migratory pneumonia extends to other lobes as each recovers, so that 
crisis is lost. 

Bilious or malarial pneumonia has prolonged chills and paroxysmal 
fever, jaundice and vomiting. 

In the aged the onset is insidious, gastrointestinal symptoms marked, 
prostration profound; fever low and irregular, local symptoms inconspicuous. 
Dullness, shallow bronchial breathing and subcrepitant or serous rales are 
to be detected. The cough may be wanting. The malady is very fatal. 

Death may follow from the specific toxemia with little involvement of 
the lung tissue, with heart failure or coma. Other organs may be infected 
with the pneumococcus. 

The inhalation of ether in cold weather, especially in abdominal 
operations, is often followed by pneumonia. Relapses are very rare. 

The course runs from three days to as many weeks or more, the average 
duration, according to Osier, being ten days. Resolution may be postponed 
to the tenth week. It may leave the lung-tissues normal, or there may be 
cirrhosis, abscess or gangrene. 

Diagnosis: — The principal points in the diagnosis are the sudden onset, 
single initial chill with rapid development of high continued fever, rapid 
respiration with moderate pulse, facial herpes, sticky gray sputa soon 
becoming rusty, crepitation in first stage only, then dullness limited to one 
or more lobes, crisis followed by rale redux. 

In acute phthisis the onset is gradual, with repeated chilliness, remittent 
or intermittent fever not ending in crisis, repeated night-sweats, no herpes, 
rapid loss of flesh, bloody purulent sputa containing elastic tissue and 
tubercle bacilli; it begins at the apex, a cavity follows consolidation, the 
other lung is invaded in time and tuberculosis follows elsewhere. 



PNEUMONIA 173 

In typhoid fever there is 510 leucocytosis, the typhoid bacillus is to be 
found, and Widal's test is available; a drop of blood, if from a typhoid 
case, added to a pure culture of the typhoid bacillus, stops the movements 
of the bacilli and induces their collection into clumps. 

In children meningitis may be taken for pneumonia; or more likely 
vice versa. Headache in pneumonia is frontal, in meningitis occipital, 
with stiff neck, restlessness, ugly temper, heightened reflexes and hyper- 
esthesia, low variable fever, no crisis, pulse irregular. 

Prognosis: — Pneumonia is more dangerous to the aged, alcoholic, 
debilitated and cachectic. Hemorrhagic cases are dangerous. Bad symp- 
toms are the absence of leucocytosis, prolonged high temperature, rapidity 
and weakness of the pulse, early active delirium, prune- juice expectoration, 
implication of more than one lobe, and the presence of complications. 
Death generally occurs from heart-failure, due to overwork and sedation 
by the pneumotoxin. Severe collateral fluxion is a condition of imminent 
danger. 

Treatment: — The treatment of pneumonia has been the battle-ground 
of centuries. Two diametrically opposite ideas as to the nature of the 
danger have led to the antagonistic principles of treatment by sedation and 
by stimulation. The ancient method consisted in a prompt vene- 
section, followed by leeches, cups, cathartics, arterial sedatives, and calomel 
as an aplastic agent, with blisters and iodine to promote absorption following 
crisis. The modern expression of this theory is found in the administration 
of veratrum viride and aconitine, acetanilid, and local applications of cold. 

The reaction against the antiphlogistic practice led to the stimulant 
treatment which has been urged with matchless force by Juergensen. 
Basing his argument on the mechanical difficulties of the circulation, he 
shows that every important element increases the work of the heart or 
subtracts from its power; and deduces a treatment by antipyretic doses of 
quinine, red wine, raw beef and cold baths. Petrescu gives digitalis by 
hundreds of grains, Wood relies on strychnine and cocaine, others on 
quinine, Bourbon whisky and other supposed stimulants. And as. both 
parties support their theories by long lists of cases treated, with a notable 
scarcity of deaths, others drop all attempts at dominant therapeutics, 
concluding that such good results from discordant methods argue the com- 
parative harmlessness of the disease; since, whichever is right, the patients 
of the others must recover in spite of the treatment. 

But pneumonia is not a notably innocuous malady. Anders gives the 
mortality in hospitals as 25 per cent; in private practice 15, and quotes 
Wells' collection of 223,730 cases with a mortality of 1 8.1 per cent. Further- 
more, it is to be observed that the results of expectant or nihilistic treat- 



174 PNEUMONIA 

ment are not as good as those secured by the use of either stimulants 
or sedatives. 

The Dosimetric Triad and Deferescent Compound are to be applied 
as described in the chapter on Treatment of Fevers; and the bowels to be 
kept clear and antiseptic. 

This method of treatment has been put to the test of clinical trial by 
thousands of physicians, not those leaders whose mastery of the art would 
carry their patients through with almost any method, but the rank and file 
of the profession, in city and country alike. The results have been so 
satisfactory that we feel fully warranted in claiming that the average 
mortality in their hands is much less than reported by Wells. The system 
has the requisite flexibility, as it is suited to sthenic and asthenic forms 
alike, and can be changed from one to the other in a moment. 

As collateral fluxion is one of the most serious conditions, it is well to 
accept the fact that a reduction of the bulk of the blood gives instant relief. 
Imminent danger of suffocation demands venesection, prompt and free 
enough to give a relief. Even if the loss of blood were to be felt severely in 
the later stages, the urgency of the present overweighs that consideration. But 
we have been too much under the influence of the reaction against blood- 
letting, and have ignored the ease with which such a loss is recouped by the 
body. Cases are exceptional in which the withdrawal of a quart of blood 
is seriously felt thereafter. The emergency may, however, be in some meas- 
ure prevented by reducing the bulk of food, and thus the bulk of the blood. 
Let the food be highly concentrated and nutritious, easily digestible or 
predigested, with the smallest quantity of water. Thirst may be relieved 
by chewing gum, or by small pellets of ice, repeated not oftener than every 
half-hour. If left to himself the patient will want it every half-minute. 
Raw white of eggs, scraped beef or grated oysters, and the beef concentra- 
tions, with small portions of junket and fresh fruit-juices, constitute the 
best diet. 

As a rule we prefer hot applications to the chest rather than cold. The 
hot mush-jacket, paste of mustard and hot molasses, hot larded flannels, 
"slap-jacks,'' etc., may sound crude to modern ears, but their efficacy is 
believed in by many excellent practicians, and they are invariably declared 
to be a comfort by the patients. The best is a dry jacket of cotton batting. 
When hyperpyrexia is present we have been compelled to apply cold 
cloths, because there was no time for the action of antipyretics. Then 
use Anderson's method: Wring a towel out of ice-water, apply it to the 
chest, or better to the abdomen, and cover with dry flannels. In one 
minute whip off the towel and replace it with a fresh one. Repeat this 
for half an hour, making thirty changes, then cover with warm flannels 



PNEUMONIA 175 

and leave an hour and a half, when, if the temperature is above 105 , 
repeat. We have kept up these half-hour applications of cold every two 
hours for five days, before the fever subsides enough to allow their dis- 
continuance. The application is designed as a means of reducing the 
general fever rather than as a local remedy. It is far easier than the 
usual cold bath and fully as effective. 

As the failure of the leucocytosis coincides with the worst prognosis, it 
is an interesting question if we should not induce leucocytosis by adminis- 
tering nuclein solution. The dose is a dram each twenty-four hours. 

The temperature of the sick-room should be kept at 65, higher with 
children, and the patient must keep his bed as long as fever lasts. Care 
must be taken to avoid any emotion or exertion capable of throwing a 
strain on the heart. One of my own patients got out of bed, walked 
upstairs, and fell dead at the top step. "Heart-failure! " 

Like many others, we began to treat pneumonia with whisky, gradually 
using less, and now for many years have used none. It is a delusion, and 
does nothing but harm. 

This constitutes the treatment of pneumonia per se, — the "dominant" 
treatment. Certain symptoms and conditions demand the application of 
variant remedies. 

The heart will not fail if the fever is kept down, the blood deprived 
of superfluous water, the alimentary canal asepticized, and the nutrition 
kept up. But the matter is so vital as to justify the routine administration 
of digitalin as advised, with strychnine when indicated, to prevent cardiac 
debility. The method of small and frequent dosage has only to be tried 
to convince one of its great superiority to Wood 's method of giving strychnine 
in a full dose, gr. 1-20 every four hours; with over-stimulus as a result 
followed by depression, which is by no means obviated by alternating doses 
of cocaine. By the method recommended a minimum dose is repeated at 
short intervals until the experienced finger on the pulse shows that the point 
of "dose enough" has been reached, and then enough is given to exactly 
keep up that effect. 

Of the remedies for collapse the best is the intravenous or subcutaneous 
injection of normal salt solution, one to three pints, repeated if necessary 

Respiratory failure may be met by adding atropine sulphate to the 
regular medicine, until the pupil begins to dilate, the skin to flush or the 
mouth to become dry. The inhalation of oxygen is indicated by cyanosis; 
continued and repeated simply as needed, without regard to the quantity 
used. As cyanosis is usually due to collateral fluxion in young adults, 
venesection is the remedy. But in the aged and very feeble, it is apt to be 
due to the retention of the secretions, the patient "drowning in his own 



17(5 SYPHILIS 

sputa" and it then calls for sanguinarine nitrate, gr. 1-20 every hour until 
relieved, with coffee and strychnine in full doses. 

Nothing relieves the pleuritic pain so completely as a leech or cup, 
applied over the painful spot. A blister is a poor substitute. 

If cerebral symptoms are marked, elimination by the kidneys should 
be carefully maintained, with gelseminine, gr. 1-250 added to each dose of 
the regular medicine, and ice to the head if required. 

Cough may require codeine and emetin,- gr. 1-67 to 1-12 each, as needed, 
but is best relieved by inhalations of steam to soothe the inflamed tissues. 
Counter-irritants over the course of the pneumogastric nerve in the neck 
are also of great value. After the crisis, expectoration may be facilitated 
by emetine, ammonium iodide or scillitin, in small doses, with mildly 
stimulant liniments or hot salt rubs to the chest. Arsenic iodide, gr. 1-67 
four times a day with calx iodata 10 grains a day, and one or two grains 
of iron iodide, form a very effective combination. The doses should be 
reduced as soon as the eyes become irritated. The writer believes the 
application of europhen in fluid petrolatum to the pulmonary tract with 
an oil atomizer, a useful means of hastening resolution and ridding the lungs 
of microorganisms. This may be employed several times daily. Care 
should be taken to destroy the sputa. 

SYPHILIS 

Quite recently Schaudinn has announced the discovery of the Spirochete 
pallida in syphilitic growths, and Siegel an entirely different organism, the 
Cytorrhyctes luis. Professional opinion now credits the former with the 
causation of syphilis, although this remains to be proved. Whether all the 
varied phenomena of this malady are likewise to be explained by the direct 
action of this microorganism, alone, is another matter. Syphilis has not 
been transmitted to any animal except man, and recently the ape. 

Infection occurs through sexual congress, accidentally by contact with 
infected persons or articles, or by heredity. The latter may be through 
a syphilitic father, though it is claimed such a man may beget a non-syphilitic 
child. There is a source of fallacy here that does not seem to have received 
sufficient attention. A woman may bear a syphilitic child, she showing no 
evidence of the disease, and yet remain immune against it thereafter. But 
if a woman is syphilitic she will bear infected children, the father 
being healthy; though as a rule either parent is most apt to infect the 
other in time, when the chances of fetal contamination are doubled. 
If the mother is infected after conception the infant may or may not 
be syphilitic. 



SYPHILIS 177 

Anatomy: — The chancre shows infiltration with small round cells, 
large epithelioid cells, giant cells, a few Lustgarten bacilli, thickening of the 
inner coats of the blood-vessels and alterations in the nerve fibers. The 
connected lymphatic glands are swollen and become indurated. 

Among the numerous secondary lesions are skin affections, condylomata, 
mucous patches, eye diseases; in the tertiary we see gumma ta and arteritis. 
Gumma forming in the bones or periosteum is called a node. The size 
varies widely. If they reach the surface they break down. They contain 
a firm caseous substance surrounded by a fibrous wall. They may develop 
in any part of the body. 

The Chancre: — The primary lesion first appears as a small papule, hard, 
like a shot beneath the skin, about a month after the infected congress. It 
is painless and apt to be overlooked, so that many patients fail to realize 
their misfortune until secondary symptoms develop. In a few days the 
tip of the nodule rubs off leaving a minute ulcer, still painless, secreting a 
trace of colorless serum. Meanwhile the connected lymphatic glands 
have swelled and are becoming hard, though not tender. There are no 
general symptoms. If suppuration occurs it is from secondary infection 
with pyogenic bacteria. If let alone the ulcer heals, leaving the 
nodule of cartilaginous consistence. The papule may be compound 
and form a patch with serpiginous ulceration resembling the track of 
a little worm. 

Secondary manifestations commence in from six to twelve weeks from the 
appearance of the chancre. Sometimes they appear in a flamboyant manner 
with high fever, delirium, followed in a day or two by an outbreak of an 
eruption resembling smallpox at first. More frequently there is moderate 
fever, of any type, continuous, remittent or intermittent, that may persist 
until recognized and treated. A peculiar anemia frequently supervenes, 
the skin a dirty or earthy tint and odor, face sallow, eyes yellow. Some- 
times part of this is due to the unskillful use of mercury, but more often it 
improves under this drug. 

The skin affections of syphilis are known as syphilides. The first is a 
papular or macular eruption, not itching, appearing over the body and 
limbs, symmetrically, lasting a week and reappearing. The patient may 
not be aware of its existence until he strips for examination. The papules 
may appear in groups. Pustules may occur so like smallpox that these 
cases have been sent to the hospital as such — a mistake the writer once 
made. Squamous eruptions also appear, which are not confined to the 
extensor surfaces like psoriasis. These syphilides are multiform, and may 
present all the above types and others at the same time. „ There is a peculiar 
"coppery" color often seen about them. 



178 SYPHILIS 

Wherever the skin is moist, in the axillae, perineum, groins, between the 
toes, at the margins of the mouth and anus, and along the inner surface 
of the labia, flat broad soft warts appear, known as condylomata. In the 
throat these are mucous patches. They are often preceded by hyperemia, 
and attended by swelling of the tonsils and salivary glands, and ulcers. 

The hair may fall in patches, or generally thinning; and the nails may 
fall or develop onychia, sluggish, with coppery indurations. 

White spots appear also on the tongue. Psoriasis is especially frequent 
on the palms and soles. Iritis occurs in three to six months, in both eyes 
successsively. The severity usually is" commensurate with the acuteness 
of the syphilides. Aural disease, parotitis, epididymitis and jaundice are 
sometimes present. 

The lesions grouped as tertiary are not definitely separated from the 
secondary. They may occur after many years or early. The writer had 
one case of hemiplegia from a cerebral gumma occurring inside of a year 
from the first lesion. The syphilides of this period tend to ulceration, and 
the scars from rupia, scattered irregularly over the back, are diagnostic. 

Gummata forming near a surface tend to break down and form sluggish 
deeply excavated ulcers; in the deeper tissues they form fibroid cicatrices. 
Much deformity results from the subsequent contraction. They are 
slightly infective. 

Amyloid disease of the liver, spleen and kidneys often follows syphilis, 
but occurs also without it. Maladies frequently following syphilis yet not 
necessarily themselves specific are termed by Fournier parasyphilitic. 
Among them are locomotor ataxia, general paresis, arteriosclerosis, and 
some cases of epilepsy. A peculiar form of dyspepsia depends on syphilis, 
coming late. The writer has occasionally been baffled in his treatment of 
dyspepsia until perhaps accidentally the patient recollected having had a 
chancre; when a few doses of calomel were at once followed by marked 
improvement. 

Hereditary Syphilis: — When born the infant may be wasted, skinny, 
weazened, like a withered old man; huge blisters or bullae on some part of 
the surface, especially the palms or soles. Soon the "snuffles" begin, the 
lips ulcerate or cracks appear at the angles of the mouth or nose, the liver 
and spleen enlarge, and the epiphyses separate. Fatal bleeding at the navel 
is not uncommon. 

These children die soon; in fact, they are often born dead. If the 
infection is less virulent the child may be born healthy in appearance, 
fattens well, and for some months retains the semblance of good nourishing. 
But snuffles have developed, resisting home treatment, ulceration occurs, 
the nasal septum necroses, letting down the bridge of the nose, and the 



SYPHILIS 179 

disease may spread to the ears and cause loss of hearing. The skin becomes 
sallow or earthy, and an eruption appears about the anus, of macules or flat 
plates; at any of the mucocutaneous junctures fissures or rhagades appear, 
whose secretion is very infectious. The hair and eyebrows may fall out; 
onychia is common; and the spleen and liver enlarge. The lymphatic 
glands do not show such marked and invariable induration as in acquired 
syphilis. The child is restless and its sleep disturbed; it may have difficulty 
in nursing, and hemorrhages may occur. 

If the child doses not die he is apt to recover showing the marks of the 
malady in his flattened nose and the aspect of premature age, with evidently 
impaired nutrition. The growth may be tardy, the forehead juts, and the 
skull is bumpy and lacks symmetry. The permanent upper central 
incisors are cupped at the cutting edges (Hutchinson teeth). 

Keratitis may occur at puberty or be delayed till the 30th year. The 
corneas seem clouded and sight is blurred. Iritis may also appear then. 
Sudden and permanent deafness may accompany the disease. Nodes 
may form on the bones, especially tibial; joint lesions, gummata develop- 
ing in the brain or internal organs, or about the vulva, and many other 
manifestations of this malady have been recorded. Fecal incontinence 
occurred in one of the writer's cases, and persisted till the 12th year; when 
it was cured by mercury and enemas. 

Osier has never met even an suspicious case pointing to transmission 
of syphilis to the third generation. 

Syphilis of the Internal Organs:— Gummata form in the brain, of all 
sizes up to a walnut. They are usually attached to the pia or dura, are 
often multiple, and become caseous. Less frequently they form in the 
spinal cord. Meningitis, subacute or chronic, occurs in connection with 
gummata. The coats of arteries are thickened. Sclerotic masses also 
form in the nerve-tissues, with areas of softening connected. Apoplectic 
effusions occur from the diseased vessels. Nerve syphilis is more frequent 
after acquired forms. It may occur after 30 years, or within three months 
of the chancre and during secondary manifestations (Lydston). 

The symptoms of cerebral syphilis are, loss of memory, change in 
disposition, headache, sudden maniacal delirium or convulsions. More 
frequently there is headache, vertigo or mental excitement, followed by an 
epileptoid convulsion leaving hemiplegia, or long-continued torpor. 
Syphilis causes general paresis or it prepares the way for it, since in a number 
of instances the connection has been noted. Finally, the symptoms may be 
those of cerebral tumors, headache, optic neuritis, cerebral vomiting and con- 
vulsions. A convulsion first occurring in a person over 30 years of age is most 
probably syphilitic, if not febrile or dependent on some other obvious cause. 



i8o SYPHILIS 

Diagnosis: — The history is important. Search is to be made for 
induration or scars from the chancre and hardened inguinal glands, for 
scars of rupia on the back and of pharyngeal ulcers, nodes on the shins, and 
other specific lesions. The symptoms are multiform, varying, and not 
defined as they would be if due to any of the known affections of the part; 
they also improve notably on antisyphilitic remedies. 

Pulmonary syphilis is very rare. It occurs as white pneumonia of 
the fetus, gummata, or as fibrous interstitial pneumonia (Virchow). The 
existence of syphilitic phthisis has not been proved. 

Syphilis of the liver occurs as diffuse hepatitis, gummata, and as a 
thickening of Glisson's capsule, hyperplasia of the connective tissue. 
Jaundice is present sometimes in infants, while in adults we see the symp- 
toms of cirrhosis, anemia with albuminuria and dropsy (amyloid disease) , 
or the tumor formed by a large gumma. The diagnosis depends on the 
history of syphilis, with irregular enlargement of the liver and good general 
health. 

Syphilis of the esophagus is rare, of the stomach still rarer. The 
small intestine and the cecum sometimes suffer, but far more frequently 
the malady is found in the rectum. Gummata develop above the internal 
sphincter, in women especially; causing obstruction by cicatrization. 

Cardiac syphilis appears as gummata, fibroid and amyloid degenerations 
and endarteritis obliterans. The latter appears in the arteries and also 
as gummatous periarteritis. The causation of arteriosclerosis and aneur- 
isms includes syphilis. 

In the kidneys we find gummata, acute nephritis, rarely leaving chronic 
nephritis in its wake. Orchitis is of diagnostic importance; gummatous 
and interstitial 

Diagnosis: — Many patients do not know they have acquired syphilis; 
many more lie about it, even to the physician they have called upon for 
treatment. The cardinal points are the history, the indurations of chancre 
or inguinal glands, the remains of eruptions symmetrical, multiform, 
non-itching, mucous patches in the throat, white patches on the tongue, 
condylomata in deep corners and about the mucocutaneous margins, 
fissures at the corners of mouth and nose, tender shins, nocturnal rheu- 
matism, palmar or solar psoriasis, scars from rupia on the trunk, areas 
of alopecia, onychia, loss of nasal septum, induration of the middle cervical 
glands and one at the bend of the elbow, the coppery hue of lesions, atrophy 
or indurations of the testes, nodes, and in women frequent miscarriages. 
In infants the bullae found at birth, snuffles, rhagades, rashes, facies and 
later keratitis, with the Hutchinson teeth, are characteristic. The cachexia 
is corroborative; the effect of antisyphilitic drugs above what would be 



SYPHILIS 181 

evident in other causes, is also of value. But potassium iodide is curative 
in many other than specific maladies. The occurrence of convuls ions for 
the first time in a man over 30, should lead to inquiry as to early syphilis. 
Loss of the nasal septum and sinking of the bridge are to be considered 
syphilitic until proved the contrary. The diagnosis is not usually difficult 
when it occurs to the doctor that he may be dealing with this disease — when 
he awakes to the possibility of it, he will find the trail of this old serpent 
in many a place apparently beyond the reach of suspicion. 

Prophylaxis: — This will include the physiologic education of the public 
and its instruction in personal hygiene. Few if any men or women can be 
hurt by continence or the limitation of sexual intercourse within legal 
limits. As marriage at an early period becomes less desirable it is wise to 
teach the young that they can prevent the development and cultivation of 
the sexual passions by keeping mind and body healthily employed. The 
devotee of athletics has little taste for concupiscence except as forced on 
him; the man whose mind is occupied by the weighty problems of life 
forgets the calls of sex. The danger lies with the weakling of either sex, 
who lolls on a sofa with books, pictures, thoughts and conversation pervaded 
by sexuality. The cultivation of true manliness and womanhood elevates 
the individual to a plane in which the animal propensities become dormant 
or at least controllable. 

Until such education becomes universal we who must deal with the 
thing that is and not with an untrue and impossible ideal, which has never 
existed since man began, must advocate legal control of the social evil, 
by which innocent persons may be protected. For the sins of the syphilitic 
are not confined to himself, but the wife and the unborn babe suffer; his 
associates and those who unwittingly come in contact with his discharges 
are infected. For this reason it is well to establish as close a supervision 
as possible over prostitutes, to insist on frequent examinations, to send the 
diseased to Lock hospitals and keep them there till cured — and the first 
requisite for this is to contrive to take away the dread these people have of 
such institutions. 

Persons affected with syphilis must be warned of the danger of contagion 
from their discharges, and the most scrupulous care taken to prevent the 
infection of others from towels, pipes, clothes, cups, kisses and other ways. 
The writer's observations have convinced him that such infections are far 
more frequent than the textbooks teach. 

Stricter supervision should be exercised over nurses and those who have 
the care of children. A wealthy and prominent family engaged as child 
nurse a woman who applied, without .much inquiry. A few weeks later 
she fell in a convulsion, and the writer found unquestionable evidences of 



i8 2 SYPHILIS 

syphilis and rhagades that might easily have infected her nursling. The 
writer has also traced infection to a medicine spoon, a cup used for drinking 
in a printing office, a borrowed pair of trousers, a lent nightgown, etc. A 
mother was infected by the dressings from her son's lesions. A syphilitic 
infant infected its wet nurse; and vice versa. A gynecologist was infected 
by a woman he was examining and lost his life from cerebral syphilis 
developing within the year. It is no legitimate argument in favor of leaving 
prophylaxis to moral sentiment to say that these are the consequences of 
sin, for they fall on the innocent, who should be protected by law. The 
greatest difficulty in moral protection lies in the remarkable indifference of 
the syphilitic as to his obligation to protect others. In fact, loss of the 
sense of moral responsibility is noted by many syphilographers as a result 
of the disease. 

Treatment: — The reason syphilis is not more frequently cured is the 
incompetence of the physician. We carelessly make use of the striking 
epigrams of Holmes and other " illustrious physicians. " We know enough 
to discount them; but to the patient they are oracular. With therapeutic 
nihilism the fashion, with fetching sneers at drugs on the lips of every 
"scientific" product of the modern schools of Germany, there is little 
wonder that as soon as suffering has ceased and visible evidences of the 
disease have disappeared, the patient quits his physician and only returns 
when driven by a fresh outbreak. Thus syphilis is indeed incurable; 
when in truth it is one of the most manageable of diseases. 

The writer has several times seen syphilis before the ulcer, when after 
an undoubtedly impure connection there had developed a hard papule on 
the penis, with as yet no enlargement of the inguinal lymphatic glands. 
The papule was excised and no further symptoms followed. Such results 
do not always follow, but since they may do so, they are well worth trying 
for. 

Otherwise there is little treatment for the local sore, except to dust it 
with calomel and protect it from dirt and abrasion by suitable dressings. 

The moment the diagnosis of syphilis is made the patient should be put 
on mercury. It makes no special difference what preparation is used 
provided it be given in the most effective manner. For this purpose it is 
necessary that the physician and patient should comprehend the correct 
theory of its action. 

Mercury in small doses stimulates excretion. Pushed to saturation and 
till toxic action commences, it causes breaking down of the feebler cell- 
structures, and if pushed will destroy normal cells. The specific cause of 
syphilis resides in certain structures already described, indurations, warts, 
patches, hyperplastic areas, gummata, etc. Under the influence of the 



SYPHILIS 183 

disease these tissues tend to spontaneous necrosis, so that their breaking 
down is a part of the history of the case. Since there is this evidence of 
enfeebled vitality in syphilitic tissues, we find that under the influence of 
mercury they melt down and are absorbed under smaller doses than are 
required to cause the destruction of normal tissues. It is therefore our 
quest to find how much mercury our patient can bear, to get the utmost 
possible effect on the disease, without quite reaching the dose that will act 
on the normal tissues. 

Begin with mercury biniodide, give gr. 3-67 four times a day; add one 
daily dose every four days, till the first evidence of toxic effect is manifested 
— soreness of the teeth or a feeling as if one or more were too long — then 
drop one daily dose and keep right on. After a time the dose may be again 
cautiously increased, or it may be necessary to lessen it. 

The essential point is that the remedy shall not be intermitted a day. 
The occurrence of salivation is a disaster, but with care it need not be 
permitted. The use of the tooth-brush, with mild antiseptic washes for 
the mouth, will prevent such trouble. 

How long shall mercury be continued ? As long as there is the slightest 
sign of the disease remaining, and for three months longer. Then stop, but 
as soon as any signs of the malady reappear resume the drug and continue 
it as before. By this means every vestige of the disease may be eradicated 
within two years; and the patient may be permitted to marry, with a clear 
conscience. Of course the couple must be kept under supervision, especially 
if pregnancy results; and the wife be dosed with mercury if there is any 
sign of the disease. The child must also be held under observation till 
three months have passed without any development. But although the 
writer has anxiously examined his patients for many years afterwards, and 
watched for evidences of the malady in their children, he has never known 
a case where the foregoing treatment has failed to eradicate the disease. 

In the prognosis a line must be drawn between the disease and its results. 
We can stop the ravages of syphilis but we cannot always restore tissues 
to their former condition. If the nasal septum is dead it will come away, 
despite mercury. If fibers of the brain have been rent asunder by a forming 
gumma we cannot bind them together and renew broken connections. 
When the conflagration has been extinguished the building may not be in a 
condition for repairs. Let the patient comprehend this, and there will be 
less dissatisfaction at the end. 

What effect has this mercurial course on the general health? A well 
man could not take it with impunity, but we are dealing with a sick man, a 
poisoned man; and poison and antidote neutralize each other marvelously. 
Under this destructive agent the patient picks up, improves in health, looks 



184 SYPHILIS 

and strength, and even puts on flesh. All the faculties of body and mind 
are powerfully stimulated. His emunctories work with feverish rapidity; 
he eats four times a day, enormously, and yet is always hungry; the debris 
of his former life is cleared out from his system and there is an indescribable 
sense of newness, of rebirth, so that as one expressed it he is even "purged 
of original sin." The mental faculties are likewise active and the sexual 
powers may be stimulated. He is living fast, and at high pressure. The 
red blood-cells multiply and gain hemoglobin. 

The writer does not believe in the curative power of potassium iodide. 
It is customary to place it by the side of mercury as another remedy for 
syphilis, but its value is slight. Syphilitic manifestations subside under it, 
less rapidly than under mercury, but the effect is not permanent. It is 
the custom to give the iodide in huge doses, up to an ounce even in a day, 
in case of such sudden emergencies as cerebral syphilis when haste is 
requisite to prevent damage to the delicate nervous tissues. But there is 
a better and quicker means of accomplishing this object. Add to each dose 
of mercury biniodide of gr. 3-67, half a grain of iodoform and gr. 1-67 of 
arsenic iodide; and you will have a combination that for efficacy and 
speed in getting to work will far exceed iodide of potassium. If glandular 
induration is to be dissolved add to the above phytolaccin, half a grain to 
each dose; and the efficacy will be enhanced. 

There are many preparations of mercury; and there are other methods 
of administration — fumigation, inunction, etc. If one feels it incumbent 
on him to do something different from other physicians, to play for the 
galleries, he can find in these his material; but as for efficacy there is nothing 
in these disagreeable and filthy methods more than the usual stomach 
administration. There is more to say in favor of the hypodermic use of 
mercury; calomel in suspension by this method seems to be absorbed 
slowly but continuously, and to exert a most surprising effect when compared 
to the doses. Once a week is sufficient. But by no method can dosage 
to effect be regulated so accurately as when drugs are given by the stomach. 

When any lesion is within the reach of local treatment, as in many of 
the skin diseases, we may with advantage apply mercurials there as well as 
internally. 

Some persons cannot take mercury; their tissues respond so strongly 
to its destructive power that even in small doses it does harm rather than 
good. Here there is an inherent weakness in the construction of cells 
that must be remedied. We may give them calx iodata, adding arsenic 
iodide, with iron iodide if anemia is present, which is not always the case; 
and from these remedies we get an excellent effect. Here also we may sub- 
stitute the vegetable resolvents — stillingin, etc. — for mercury, with great 



LEPROSY 185 

benefit. As the latter is given for its specific antidotal power there is 
nothing to hinder the simultaneous use of any tonics or other remedies that 
may be indicated by the peculiar conditions present in any case. Failure 
to comprehend this is one reason for the preference of potassium iodide 
in tertiary cases, where tonics are usually required. 

In congenital syphilis it may be convenient to employ mercurial oint- 
ment smeared on a flannel bandage and applied about the waist. The 
writer's preference is for mercury with chalk, by the stomach. 

We are aware that the prognosis we have given as to the complete 
cure of syphilis is more favorable than the textbooks warrant. But we 
have been in the habit of adhering to the radical treatment described, 
and of knowing that it was carried out as directed, and from such methods 
results are obtained. 

LEPROSY 

The dread with which this malady is regarded is a relic of the importance 
attached to it by the ancient Hebrews. So great was their terror of it that 
Berosus accounted for it by declaring the Hebrew race was derived from 
lepers gathered and expelled from Egypt by the Pharaohs. Modern 
researches show that a number of skin diseases were included under the 
name of leprosy in Bible descriptions, and that while contagious it is far 
less so than almost any other contagious disease, and infinitely less to be 
dreaded than tuberculosis. 

Leprosy exists at present in the Acadian districts of Louisiana where 
over 100 cases are known; among the Chinese in California and there it has 
attacked some whites; in the Norwegians in Minnesota where it is decreasing 
and is not known to have attacked natives; and among the descendants 
of the French in Nova Scotia and New Brunswick. Scattered cases, 
usually Chinese, are discovered occasionally in the great cities. It occurs 
throughout the West Indies, in Brazil, many cases in Hawaii, but its princi- 
pal habitation is in the crowded empires of Asia where cases are numbered 
by hundreds of thousands. Hence it spreads to every land that admits 
the Chinese. 

The cause of leprosy is a specific bacillus discovered by Hansen. It 
bears some resemblance to the tubercle bacillus. 

Leprosy is probably inoculable. Heredity simply offers opportunities 
for contagion, which is the principal method of transmission. The rjacilli 
are given off in saliva, expectoration, nasal mucus, urine and milk; and 
have been found in dust of rooms occupied by lepers. The bacilli are 
believed to enter the body through the skin and mucosa. The number of 



186 LEPROSY 

laundresses affected indicates transmission by clothing. Hutchinson 
believed that the use of fish predisposed to leprosy, as certain districts 
in Spain are affected where the use of fish is common; but as this comes 
from Norwegian fisheries it may be an instance of bacillus transmission. 

Contagion is slight; there is little possibility of nurses and physicians 
becoming affected; but those who live with lepers tend in the course of years 
to become leprous. When lepers are segregated there is a slow but con- 
tinuous decrease in the number of cases; when allowed to go about freely 
there is a slow but steady increase 

Anatomy. — The tubercles of leprosy consist of connective stroma with 
granulomatous cells in the reticular spaces; vast numbers of bacilli in and 
about the cells; spreading, the center of patches ulcerating and cicatrizing, 
and involving the skin and accessible mucosa. Toes and fingers are severed, 
and great deformity results from cicatrization. In the anesthetic variety 
bacilli settle in nerve trunks, the cutaneous areas supplied becoming white 
and numb. 

Symptoms: — Sharply defined and hyperesthetic areas of erythema 
appear on the surface of the body, becoming pigmented; then the patches 
become numb and white, or sluggish nodules form, which gradually spread 
at the edges and ulcerate in the center. The hair falls, the eyes, mouth and 
larynx are attacked, and death may result from implication of the lungs, 
The anesthetic form begins with pains in the limbs, areas becoming hyper- 
esthetic or anesthetic, blisters form, pigmented patches appear and fade 
leaving numbness, ulcers follow the blisters with subsequent cicatricial 
deformity, and the termini of toes and fingers are dropped. The course 
is very slow. 

Diagnosis: — Dusky erythematous patches, hyperesthetic or anesthetic, 
are characteristic. The fully developed disease can scarcely be mistaken. 
Lupus leaves cicatrices behind its slowly advancing nodules but the area 
is not anesthetic. Examination of the nerve trunks with the microscope 
will settle any doubtful case. 

Treatment: — Dyer reports cures from the use of Calmette's antivenene; 
but these had not when reported stood the test of time. Chaulmoogra 
oil has proved curative in Japan. It must be given in doses pushed to 700 
drops a day and continued many months. But it, like wintergreen oil for 
rheumatism, soon becomes so nauseating that it is difficult to induce the 
patient to continue it. 

Does this oil, like cod-liver oil, depend on one or more active principles 
that can be extracted, like morrhuol, or does it like oil of wintergreen depend 
onthe peculiar acid it contains — gynocardic ? In either case the separation 
of the oil and rejection of the useless part would solve this question, as the 



TUBERCULOSIS 187 

separation of salicylic acid did in the case of wintergreen, and enable us to 
utilize this remedy to its fullest power. This question seems to be left for 
the enterprise of coming generations. As separation of the leprous from 
the rest of the population, in lazarettos, is followed by cessation of the 
spread of this malady to new subjects, it should be enforced as strictly as 
possible. It seems necessary that the condition of lepers shall be made 
more comfortable than at present, however, to remove their disinclination 
to segregation, that now leads to concealment of patients until they have 
transmitted the infection to associates. 

TUBERCULOSIS 

Etiology: — In 188 1 Robert Koch discovered the true cause of the 
disease, the tubercle bacillus. This discovery was foretold by Niemeyer, 
who described clearly the symptoms and lesions of phthisis before and 
after the advent of the bacillar invasion. His views have been verified 
by the observations made in our thirty-five years' clinical studies; and 
though at present not held by the leading teachers, we expect to see them 
confirmed before many years, and to see the profession swing back to the 
level of his teachings. At present the bacillus has carried the pendulum 
too far to one side. 

We have indulged in a little prediction ourselves; and, as we claimed 
over ten years ago, it has been found that the tubercle bacillus does not 
monopolize the destruction of the human lung. In examining sputa at 
the laboratory we find tubercle bacilli, pneumococci, influenza bacilli, 
strepto-, staphylo-, and gono-cocci, and sometimes typhoid bacilli, variously 
combined. Until we are able to differentiate the effects of these organisms 
we must treat of phthisis as a simply tubercular or as a mixed infection. 

Phthisis prevails in every inhabited country of the globe, from the 
poles to the equator. It is most prevalent when the population is crowded, 
poor and dirty; less frequent as we approach the poles or ascend above 
the sea-level, for the simple reason that population there becomes sparser. 
Statistics showing less prevalence of this malady at 5,000 feet above the 
sea-level, and almost a total absence of it at 10,000 feet elevation, must 
be read with the knowledge that the vast bulk of the world's inhabitants 
live less than 5,000 feet above the sea-level, and very few above 10,000 feet. 
If among the few scattered thousands, out of a billion and a half, there are 
still some tuberculous individuals, it speaks strongly for the universality 
of this dreaded microbe. There are reasons, however, for some degree 
of immunity in mountaineers. The thin air causes unusual development 
of the lungs, as their swelling chests testify; the pure air is free from 



188 TUBERCULOSIS 

bacteria, and the sparse population renders successive infections unlikely. 
The outdoor life, the rude exercise, the absence of city dissipations, con- 
duce to health in those not killed off by the privations. 

Pathology: — While the lung is most frequently the seat of tuberculosis, 
it may affect any other part, the order of frequency being the larynx, 
intestines, peritoneum, genitourinary apparatus and brain; in children 
the lymphatic glands, intestines, bones and joints. Sooner or later, the 
malady attacks the lungs, also. The entrance of the tubercle bacillus 
into lung-tissue is followed by proliferation of the connective tissue and 
epithelium, formation of giant cells and influx of leucocytes, both possibly 
for phagocytic defense. Tubercles measure 1-2 to 3 mm. in diameter, 
are at first transparent and non-vascular. A netting of connective tissue 
surrounds the tubercle and shuts it off more or less effectually from the 
surrounding tissues. The tubercle undergoes either caseation or sclerosis. 
In the former case the cells become yellowish, amorphous, growing at 
the margins till they unite in masses. These either soften and break 
down into cavities, or are encapsulated, the cheesy contents becoming 
chalky, the tubercular process extinct. 

In sclerosis hyaline transformation of the mass occurs with the forma- 
tion of fibrous tissue, the process extending into the surrounding pul- 
monary structures. Contraction follows as in other cirrhotic affections. 
Caseation and sclerosis often coexist. Calcification and sclerosis are evi- 
dences of cure, of the body's success in the battle with the invading bacilli. 
If the invaders are few and the body well-supplied with the phagocytic 
leucocytes, producing the defensive proteids in abundance, the victory 
goes to the defense. The processes may be confined to one or a few 
points, or may involve a lobe, a lung, or both lungs. 

Surrounding the tubercle is a zone of inflammation caused by it, in 
which fibrosis occurs. Into this the bacilli may penetrate, extending 
the disease process, or it may become circumscribed, checked or even 
extinguished. Sometimes the first focus is thus cut off, and in it the 
bacilli remain, quiet but alive, until at some time, perhaps after years, 
circumstances allow their egress into the lung or other parts of the body 
and the fight is resumed. Various bacteria unite in the struggle, causing 
destruction of lung-tissue, fever, hectic, sepsis, etc. 

Koch's bacillus is a curved rod, in length one-third to one-half the 
diameter of a red blood-corpuscle, the ends rounded, non-motile, with 
spots representing vacuoles. Stained bacilli have a beady appearance. 
They are best grown in blood-serum, at a temperature between 98 and 
ioo° F. Heat the serum till coagulated; on cooling rub on it the cut 
surface of a bit of tuberculous tissue, leaving it on the surface. In two 



TUBERCULOSIS 189 

weeks appear colonies of dry grayish scales. If with these guinea-pigs 
are inoculated tubercles appear in about three weeks. From cultures an 
albuminoid substance has been extracted, which causes fever when injected 
into the body. It is a nuclear proteid, not a toxin. A ptomain and 
extract have also been separated. Part of the symptoms are due to the 
production ofthese toxins. Outside of the body the bacilli live an unknown 
period, withstanding extreme cold, water or dryness, but killed by a few 
minutes' boiling or by exposure to the sun's rays. They are believed to 
be incapable of reproduction except in an animal body. 

The liability to tuberculosis is great in those who change from an 
open air to house-habitation. The Indians who leave their tepees for 
houses die off rapidly of tuberculosis. 

Those who have recovered their health by a life in the open air will 
find it trebly perilous to return to living within six walls. Better is it 
that they recognize their loss of resisting power and continue the habits 
and the milieu to which they owe their recovery. 

Tuberculosis is usually acquired through air inhaled. Infected men 
and animals give off bacilli in coughing, sneezing, talking and laughing. 
Food is thus frequently infected. Transmission is less frequent from 
man to man than from an infected dwelling. This has been shown by 
Flick's studies of the prevalence of the malady in Philadelphia, where 
centers of infection were proved. Numerous cases are also recorded of 
obvious direct transmission. Transmission also occurs from the milk 
or flesh of tuberculous animals, or from food infected by tuberculous 
discharges, in dust, etc. The non-tuberculous portions of a tuberculous 
animal do not carry infection. Flies probably carry bacilli on their feet 
to food. Inoculation may transmit the disease, as by the bite of a con- 
sumptive, handling infected foods, dissection wounds, abrasions on laun- 
dress' hands, etc. The bacillus having been found in the fetus, we must 
admit the possibility of direct heredity, but usually it is only the morbid 
susceptibility to the malady that is so transmitted. 

The negro is more liable to tuberculosis than the white, the Indian 
more than the negro. Children of consumptives are more liable, and 
more exposed to direct infection. Many other infections like measles 
predispose to tubercle. Most cases develop between the ages of 20 and 30 
years. All ages are liable. Females are slightly more frequently affected, 
especially during pregnancy. Humidity and variable weather favor its 
occurrence, and it is rendered less prevalent by draining marshes and 
ventilating dwellings. Among local causes may be mentioned occupations 
involving the inhalation of dust, the occurrence of bronchitis, pneumonia, 
hemoptysis, pleurisy, pulmonary artery stenosis, thoracic trauma, or tumor. 



iqo ADENITIS 

All morbid influences that impair the structure or weaken the vitality 
of the lung tissues, open the door to tubercular infection. 

ADENITIS 

This form of tuberculosis occurs in children and young adults. 
The infection is less virulent than in other forms. It may be local 
or general. The cervical glands are most frequently affected. Bacilli 
constantly fall on the nasopharyngeal mucosa, and if vitality has been 
lowered by catarrh the intruders may reach the glands. The primary 
infection may be in the tonsils or the teeth. Cutaneous wounds or eczema 
may offer an open door. Formad found in " scrofulous"perscns that the 
perivascular lymph-spaces were more or less occluded by granular debris, 
hindering the free ingress of leucocytes, and affording a secure refuge for 
invading bacilli. The glands enlarge, first the submaxillary, even to 
the size of an egg; as suppuration occurs the skin becomes adherent and 
if let alone they discharge externally. Fever, anemia and emaciation 
may attend. The whole chain of cervical glands may enlarge, forming 
a solid mass extending from ear to ear. The axillary and bronchial 
glands may be involved. The diagnosis may be made by the enlargement 
and by the tuberculin test. Tubercle bacilli may be found in the pus. 
The course is tedious, mostly ending in recovery. 

The bronchial glands may be affected primarily or following pulmonary 
tuberculosis. Caseation occurs, ending in abscess or calcification. If 
they open into the air-passages cough results with discharge of pus, blood 
and debris of the disintegrating tissue. The lung may be thus infected 
from glands long quiescent; or the pericardium may be invaded. 

The mesenteric glands may be affected primarily or secondarily to 
intestinal infection. Local pain and tenderness follow the peritoneal 
involvement, with effusion. The nodules may be felt. The diarrhea is due to 
intestinal ulceration, tubercular. Fever eats up the fat, and causes anemia 
and debility. The diagnosis is not difficult. The malady occurs in children. 

Rarely there is a general tubercular adenitis without other involve- 
ment. The fever is remittent or intermittent, wasting rapid, the strength 
failing fast, and the enlarged glands may be palpated. The malady is 
chronic, unless suppuration occurs. 

We must not conclude that all the enlarged glands are necessarily 
tuberculous. The writer had one case in which the cervical glands were 
swollen into a mass from ear to ear; he opened the coverings and found 
five glands were yellow with suppuration; these were removed, when the 
swelling of the rest promptly subsided and in a very short time there was 
scarcely a trace of the disease remaining.. 



ACUTE TUBERCULOSIS iqi 

Whenever the malady is within reach — and what part of the human 
frame is beyond the modern surgeon's knife ? — the diseased glands should 
be enucleated and removed without opening them. The treatment then 
is that of tuberculosis in general. Carious teeth are probably the most 
frequent avenue for the entrance of tubercle bacilli in this malady, and 
prophylaxis would suggest having the primary teeth filled whenever 
decay begins in them. 

ACUTE TUBERCULOSIS 

In this disease there may be an acute general infection of many or all 
the organs of the body, with development of miliary tubercles. 
An old focus has probably discharged into the circulation. The lungs, 
liver and spleen are most affected. This is more frequent in early life, 
the original focus being in the lymphatic glands, lungs or kidneys. It 
may follow measles, whooping-cough, typhoid fever, influenza or pneu- 
monia. Miliary tubercles may exist in many parts of the body and cause 
no appreciable symptoms. They have been detected in the choroid. 

In the typhoid form the symptoms begin with prodromes of malaise, 
headache, chilliness, fever and growing debility, or abruptly with high 
fever, weak, rapid pulse and mental sluggishness or delirium. The 
tongue is brown and dry, respiration rapid, with cyanosis and pallor. 
The hectic flush accompanies the fever acme daily. Epistaxis is not 
common. Prostration follows the fever, pari passu. Wasting is so 
marked as to be diagnostic. Nervous symptoms are less prominent. 
The pulse is rapid as compared with fever, irregular if the meninges are 
affected. There is little cough, but breathing is hurried and labored; 
little expectoration, not tubercular unless an old lesion is present and 
discharging. The physical signs are those of any disease present. The 
appetite is lost, nausea may occur, and thirst is marked. The spleen is 
slightly enlarged. Tubercles may be found in the choroid by the ophthal- 
moscope. 

The diagnosis from typhoid is based on the history, evolution, fever 
chart, rapidity of pulse relative to fever, rapid breathing, dusky pale face, 
absence of abdominal symptoms and rash, of Widal reaction and knee- 
jerk, rarity of epistaxis or intestinal hemorrhage, and the presence of 
tubercles in the choroid and tubercle bacilli in the blood. 

The pulmonary form may develop suddenly, with chill, followed by 
fever, or after a period of failing health, acute infections like measles 
frequently preceding the outbreak. Dyspnea, rapid breathing and other 
evidences of pulmonary implication occur early and decidedly. Cough 



192 TUBERCULAR MENINGITIS 

is prominent. General symptoms resemble those of the typhoid form. 
Bronchopneumonia is manifest, fever high, pulse fast and irregular, 
nervous symptoms not marked. The course is longer than general miliary 
tuberculosis except in children. Suffocative phenomena increase and 
cause death. The diagnosis is made by the history, the bacilli in the 
sputa or the blood, sometimes in the choroid, and by the gravity of the 
general symptoms. 

TUBERCULAR MENINGITIS 

Tubercular meningitis is frequent, occurring at any age but mostly 
between two and seven years. The infection is usually from bronchial 
glands, a fall often preceding the outbreak, and it is sometimes associated 
with erythema nodosum. 

The pia at the base of the brain is usually the seat of the tubercular 
deposit in children, the vertex in adults. The membrane is inflamed 
in the former, less frequently in adults. The exudate is gray, transparent 
and gelatinous, with few or many tubercles enmeshed. They may be 
found in the arteries when not elsewhere. The cerebral convolutions are 
flattened by pressure, the cortex softened, red, rarely white. 

During a week of prodromes the child is peevish, pale, complains of 
headache and photophobia, and grinds its teeth in sleep. The tongue 
is coated, appetite absent, vomiting, propulsive or regurgitative, bowels 
constipated. The urine may be scanty, the abdomen sensitive. Wasting 
begins at once. Rarely the onset is acute, with excitement. The invasion 
is gradual or sudden, with severe vomiting, chills followed by fever, and 
headache. The irritability is extreme, with screaming, sometimes early 
drowsiness. The attack may commence with convulsions, wild delirium, 
paralysis or coma. The headache is increased by light, sound or motion; 
the hydrocephalic cry is given, vertigo is present, the pupils contract, 
the face pales and flushes, the expression is sad or dull, and the mind may 
wander. The tache cerebrate may be manifested. Vomiting does not 
depend on gastric conditions. Sleep is disturbed by starting, fever is 
moderate, rising toward evening. The skin is dry and harsh, the pupils 
dilate and expand irregularly, ptosis appears early. The pulse is at first 
relatively slow, becoming faster and irregular. 

In the stage of transition the patient quiets some, is duller, cries less, 
vomits less, complains less, the abdomen is boat-shaped, the head retracted, 
constipation obstinate; strabismus, ptosis and palsies of various nature 
indicate local foci forming. There may be tremors, general convulsions 
or athetoid movements. As pressure supervenes the pupils dilate. Res- 
piration is irregular and sighing. 



ACUTE PHTHISIS 193 

In the paralytic stage the patient becomes duller, comatose, local or 
general spasms occur, optic neuritis develops, ocular palsies increase, the 
pupils dilate, the eyes arc half closed and the balls may oscillate, and local 
paralyses develop. The temperature becomes subnormal, but is hyper- 
pyretic just before death, the pulse fast, weak and irregular, with anes- 
thesia and muscular relaxation. The typhoid state may develop before 
death. Leucocytosis may occur. The optic disk is hyperemic, swelling 
and striation follow, and choroid tubercles may be detected. 

The diagnosis is made by the ophthalmoscope, the tuberculin test, 
and lumbar puncture to distinguish from cerebrospinal fever. Syphilis 
and traumatic meningitis are to be excluded. 

The type may be mild, malignant or chronic. Acute cases end within 
a month, chronic ones last several months. Remissions may occur. 
Some cases are known to have ended in recover}'. 

The older treatments having failed, the way is open for trying the 
newer methods and remedies. 

ACUTE PHTHISIS 

Acute forms of phthisis may be either tubercular or nontubercu- 
lar. Of the latter form the following case may serve as an example: 
The superintendent of a cemetery, a young man of slender build but 
healthy in person and habits. The body of a woman dead of " consump- 
tion"- had been placed in a vault. When the vault was opened it was 
found that the body, which had been enormously swollen at death, had 
burst and the fluids had covered the floor of the vault. The stench was 
so great that the employees, though accustomed to such work, refused 
to enter the vault. Phenol in large quantities was thrown in, and the 
superintendent to set an example entered first, and remained for some 
time until the cleaning was done. He was seized with shivering, followed 
by high fever, violent cough, the sputa remaining liquid after 48 hours 
from the time they were ejected. The temperature was 105 F. and over, 
night-sweats came on, with rapid failure of strength and emaciation, but 
a remarkable absence of the concomitant symptoms, as the man scarcely 
kept his bed. The sputa was thin, copious, serous, and pronounced by 
the bacteriologist to consist of a pure-culture of " bacterium termo, " 
there being no tubercle bacilli. For several days the patient exhaled the 
odor of phenol and the urine became dark. 

He improved somewhat and was sent to San Antonio, Texas, where 
he resided for some years, recovering entirely, according to his own report 
ten years later. 



i 9 4 ACUTE PHTHISIS 

In 1869 a man was brought into the clinic at Charity Hospital, Cleve- 
land, with the diagnosis of acute phthisis. This was questioned by that 
fine diagnostician, Prof. Scott, on the ground of insufficient evidence. 
The only symptoms were fever of 104 F., rapid respiration, slight cough, 
and a sensation of oppression in the chest, with just enough gastrointestinal 
irritation to arouse the suspicion of typhoid fever. The patient died in 
four days, and at the autopsy his lungs were literally stuffed with miliary 
tubercles, in phenomenal numbers, there being not a spot where a pencil- 
point could be put that was free. Prof. Scott dwelt on the fact that there 
had been no dullness on percussion. 

Four robust, healthy Irishmen, engaged in the particularly healthful 
occupation of peddling coal about the streets of the city, slept in a room 
so small that their two beds and a wash-stand filled all but just enough 
room to open the door, so that they had to climb into bed over the foot- 
board. One contracted tuberculosis, and lived about three months. 
The second to be attacked was likewise affected, and died in six weeks. 
The third was seized while these two were still occupying the room, and 
he died in four days. The autopsy showed a condition of the lungs closely 
similar to that of Dr. Scott's patient as detailed above. Here we have all 
the conditions necessary for the most virulent infection, these illiterate 
men being confined in a very small room, with no ventilation, spitting on 
the walls and bedding until the air was saturated with the bacilli. 

Several cases of acute tubercular phthisis came under our observation 
in a paper-box factory. Many girls worked closely crowded in one room, 
the windows usually closed because the drafts interfered with the gas-jets 
employed to keep the glue-pots warm. Some among these girls were always 
consumptive, and the contagion was thus transmitted in concentrated form. 
The course was from six to twelve weeks. 

The malady may simulate lobar pneumonia, or in children broncho- 
pneumonia. The course may be acute or subacute. 

Symptoms: — The onset is sometimes marked by a chill resembling that 
of pneumonia, or by a period of depressed health, with dyspnea, bronchial 
hemorrhage, hard dry cough, fever running very high, rapid wasting, 
hurried breathing, anorexia, constipation, night-sweats, and inability to 
breathe comfortably while lying down. The face has a curious smoky 
look sometimes, or there may be cyanosis. As the malady advances there 
are symptoms of general bronchopneumonia, crepitus, slight dullness or 
increased resonance, the patient complaining of a stuffy sensation in the chest. 
The pulse is rapid and weak. The fever in very acute cases is apt to exceed 
105. Epistaxis sometimes occurs. Debility and wasting progress rapidly. 
Delirium and other nervous phenomena depend upon the fever present. 



ACUTE PHTHISIS 195 

The diagnosis is often difficult, but the hurry of respiration, rapid 
development of the fever and its height, cyanosis and other evidences of 
pulmonary involvement, without physical signs of pneumonia or the 
abdominal symptoms of typhoid fever, usually indicate the malady, which 
is confirmed by the presence of numerous tubercle bacilli in the sputa. 
Examination of the blood shows leucocytosis only if suppuration is going 
on. Tubercles may be detected in the choroid. 

In less acute cases the examination of the sputa for bacilli may be the 
only means of surely diagnosing the tubercular affection from various 
pulmonary inflammations. A whole single lobe may be involved in the 
tubercular affection, the course simulating that of pneumonia with missed 
crisis. Bronchial hemorrhages more frequently are followed by subacute 
than by hyperacute attacks. The sputa is usually thin and serous, and if 
ejected upon a handkerchief remains liquid instead of drying up. If 
bronchial hemorrhage occurs the sputa thereafter contains blood or its 
debris, with the mucus and pus supplied by the consequent inflammation. 
The physical signs are those due to consolidation of the lung-tissues, and 
the presence of secretion, varying with its quantity, consistency and location. 
Death usually occurs before there has been time for consolidation or cavity 
formation. As usual in tuberculosis, the patient is hopeful to the last. If 
the case is prolonged till a cavity has formed the sputa contains elastic 
fibers from the disintegrating lung-tissues. Hemoptysis may occur 
towards the last from erosion of an artery, and may be fatal. 

Prognosis: —The prognosis is bad if the lung is universally affected, the 
sputa swarming with tubercle bacilli or streptococci, the course rapid, the 
fever persistently high, and if hemorrhage from erosion occurs. Niemeyer 
did not consider non-tubercular "galloping consumption" necessarily 
fatal, and McCall Anderson reported cures. Our two cases of non-tuber- 
cular bronchopulmonary mycosis recovered. 

Treatment: — It is of the utmost importance to subdue the inflammation 
before it has disorganized the pulmonary parenchyma. For this purpose 
an effective method is the application of ice-cloths to the abdomen, 
changing every minute for half an hour, and repeating even' two 
hours while the fever is above 103 degrees. Internally the most satis- 
factory antithermic is a combination of guaiacol and piperazin, gr. 3 to 5 
each every four hours. Gr. *j\ of guaiacol rubbed into the skin over the 
lung has also shown an efficacy that is remarkable, as this agent is not 
antipyretic when given internally alone, except as an intestinal antiseptic. 
For slighter fever the oft-recommended combination of aconitine, digitalin 
and strychnine arsenate is most useful. The bowels must be kept free by 
the use of mild, non-depressant saline laxatives, and aseptic by calcium 



196 ACUTE PHTHISIS 

sulphocarbolate gr. 30 to 60 daily. Decided comfort sometimes follows 
the application of a cotton jacket to the chest. Night-sweats are 
restrained by atropine or agaricin until the antipyretic measures have 
had time to act. 

The food should be highly nourishing, easily digestible, and free use made 
of the artificial digestants, papayotin, diastase and acid-pepsin. Milk, 
eggs, oysters, beef , game, terrapin or turtle, fruit juices, and the concentrated 
albuminoids popularized in recent years, are the best foods; though it 
must not be forgotten that persons differ as to their digestive capacity and 
tastes, and that each will do best on what he likes best. Beyond this the 
treatment is symptomatic. 

Calcium sulphide has been recommended as a direct antagonist to 
bacteria, and for its undoubted power of checking suppuration. It should 
be given in full doses, gr. 10 to 20 daily of the pure salt, continued until the 
odor of the breath and skin show the body to be saturated with the drug, 
and then in smaller doses to keep up this effect. 

The production of leucocytosis by the administration of nuclein has been 
also advised. Those who have reported the best results from it gave it in 
very large doses, up to half an ounce of the standard solution, daily, by the 
skin or mouth. The idea is too important to be allowed to go by default, 
and should be tested thoroughly. Too many remedies have been introduced 
and allowed to fall into oblivion without a true trial. 

Whether sprays or vapors ever reach the seat of the disease or not, they 
are useful in relieving the coUgh and cleansing the pulmonary tract of 
secretions. Let the patient steam the lungs by inhaling the fumes of boiling 
vinegar for ten minutes, and then spray with menthol camphor in albolene, 
or europhen in fluid petrolatum. This soothes the irritated tissues, and 
usually permits a good night's sleep, undisturbed by coughing. 

The sickroom must be constantly disinfected by the vaporization of 
volatile oils, eucalyptol or cinnamon, and by thorough ventilation. Injury 
to the patient resulting from reinhalation of the floating bacilli is more 
dangerous than any possible exposure to the outside air. Some consump- 
tives bear the fumes of burning sulphur in an astonishing manner, and then 
this method of purifying the air is to be preferred. But while there is fever 
the patient should be in bed, and climatotherapy applies rather to the chronic 
forms of the malady. 

OTHER FORMS 

Tuberculosis of the lip is rare, appearing as an ulcer. The tongue, 
palate and especially the tonsils frequently form the open door for the 
infection. In the pharynx, esophagus and stomach the disease is rare. 



TUBERCULOSIS 197 

In the bowels it is common in children, from milk infection. This occurs 
also in adults. The peritoneum and mesenteric glands are involved. 
When it follows pulmonary phthisis the lesions are usually in the lower 
ileum, the cecum and ascending colon; sometimes in the rectum, primarily 
or secondarily. Deposits occur in the glands, caseate, and break down 
into ulcers irregular in shape, the edges infiltrated or caseous involving 
the submucous and muscular layers, with colonies in the serosa, and in 
acute cases showing little tendency to repair. In chronic forms the 
cicatrices may distort or obstruct the bowel. 

There may be few symptoms in children, or merely an obstinate diarrhea, 
colic and blood, pus and sago-grains in the stools. Constipation may be 
due to peritonitis or cicatrization. There is fever and progressive emacia- 
tion, the diarrhea resists treatment and may be aggravated by opiate. 
Tender spots are often demonstrable. The lungs may be also affected. 
Tubercle bacilli may be detected in the intestinal mucus. Colicky pains 
are characteristic. 

Serous tuberculosis is secondary as a rule, acute or chronic. This and 
other local tuberculoses are treated in connection with the organs affected. 

The treatment of fever in the tuberculous deserves special consideration. 
The writers have expended much thought and experiment and perused 
many works, in the endeavor to find an effective treatment for the fever of 
tuberculosis. In the older days we attempted to smother the fever by the 
use of quinine and the coal-tar antipyretics. N.emeyer's modification of 
Heinrs pill was a distinct step in advance, and its value was approved in 
many instances. Nevertheless no such success ever followed the writer's 
use of any remedies, including the foregoing, as he secured by applying the 
simple method of intestinal antisepsis above described to these cases. By 
clinical experience, during a number of years and embracing many cases, he 
has been convinced that autotoxemia, from the absorption of toxic matter 
from the alimentary canal, is the cause of one to two degrees of fever in the 
tuberculous, and that this may be removed by the methods above described. 
Whether this portion of the fever is due to the absorption of the ordinary 
fecal contents of the bowels, or whether the swallowing of tubercular sputa 
has something to do with it, he is not prepared to say; but this much is 
certain, that the fever is not due to tubercular ulceration; or if it be, the use 
of calcium sulphocarbolate in doses of 40 grains a day, after complete 
evacuation of the bowels, has a curative effect which is not displayed by any 
other known method of medication. Not only is the fever subdued by this 
method, but appetite returns, and the entire condition of the consumptive 
is so markedly changed for the better, that one questions whether so much 
improvement can be possibly secured from any direct medication of the 



198 GLANDERS 

affected lungs. The writer, if confined to a single remedial measure in the 
treatment of pulmonary consumption, would cheerfully lay aside every 
other to retain the intestinal antiseptic method. 

GLANDERS 

Sometimes men who frequent stables contract from the horse this malady, 
known as glanders when it affects the nostrils, farcy when it appears under 
the skin. It is an infective granuloma due to bacillus mallei. This is a 
short non-motile rod much like the tubercle bacillus. Infection occurs 
in the nostrils or through an abrasion of the skin. The lesion is a mass of 
lymphoid and epithelioid cells, containing the bacilli. These break down 
into ulcers or abscesses. 

The acute form has a -brief incubation,about three days. There is 
some fever, with disturbance at the site of infection, and lymphatic involve- 
ment, the nodules forming and soon breaking down, causing mucopurulent 
discharge. Papules appear, soon forming pustules resembling smallpox. 
The nose swells, necrosis follows, pneumonia may occur, the lymphatic 
glands swell, and the patient dies in about a week. 

In chronic glanders — rare — ulcers form in the nose and throat, dis- 
charging like coryza ; it runs on for months and may get well. The diagnosis 
requires the use of mallein, or the methods of the bacteriologist. 

In acute farcy there is intense local reaction and an inflammation 
resembling vaccination. The lymphatics are inflamed and form knots 
called farcy buds along their course. Arthritis, abscesses in the muscles 
and connective, sepsis, etc., are the symptoms. The bacilli may be found 
in the urine. Death occurs within two weeks. 

Chronic farcy shows tumors on the extremities, with little reaction but 
ulcers or abscesses forming. There is less lymphatic involvement. It may 
last years, or death result from sepsis, or the acute form. 

Glanders may be transmitted from man to man. Laundresses are 
liable to it from washing infected clothes. 

The treatment is the earliest possible application of caustics, to destroy 
the infectious focus at once. Farcy buds should be opened and caustics 
applied. Antiseptic dressings may then be employed, but if cauterization 
has been thorough they are unnecessary, if not they are useless. The 
strength should be kept up by scientific feeding and the best tonics and 
reconstructives. 

Mallein, a product of the glanders bacilli similar to tuberculin, has been 
employed by veterinarians as a means of diagnosis, and of late is being 
further used as a remedy for this affection with promising success. We 
have not heard of its employment for man, 



ACTINOMYCOSIS 199 

ACTINOMYCOSIS 

The ray-fungus, streptothrix actinomyces, causes in cattle a disease 
known as lumpy-jaw, and sometimes men are infected. It occurs in the 
discharges as yellow, sulphur-colored grains, up to two millimeters in 
diameter, composed of cocci and threads interwoven. The organism has 
been cultivated and reproduced the disease. 

Infection seems to take place through food, the mouth being most 
frequently the location of the attack. It produces granulations like those 
of tubercle, containing epithelioid and giant cells, with small round cells. 
As it grows hyperplasia of connective tissue takes place, with suppuration, 
which may also be caused directly by the organism. 

Israel reported the germs found in carious teeth. The jaw is frequently 
affected, and the tumor has usually been mistaken for sarcoma. Granula- 
tions may occur on the tongue, the intestinal mucosa about the cecum and 
appendix, or in the colon. The organisms have been detected in the feces. 
The liver may be affected primarily. 

Seated in the lungs it gives rise to chronic, infectious bronchopneumonias 
with cough, fever, wasting and purulent fetid sputa. It is usually one-sided. 
It may present the aspect of bronchitis, miliary tubercle or bronchopneu- 
monia with abscess. Secondary actinomycotic abscesses may follow in any 
part to which the germs may be carried. The fever depends on suppuration 
and is of septic or hectic type. 

There may be a typhoid condition. Death is the usual termination, 
in less than a year. Diagnosis may be made by the fetid sputa, containing 
the organisms. • 

This fungus has been detected in certain cutaneous ulcers. Their 
course is very chronic. One case of cerebral actinomycosis has been report- 
ed and two of pleural infection. 

The diagnosis is made by the microscope. 

The treatment is surgical — complete removal of the infected tissues. 
Thomassen has reported a number of cures from potassium iodide in doses 
of a dram daily. If this is true, why may not any of these infections be 
cured by saturating the body with substances that render it unhabitable 
by the specific organisms ? 

Far more powerful than potassium iodide is the combination of arsenic 
iodide gr. 1-67, mercury biniodide gr. 3-67, iodoform gr. 1-12, and phyto- 
laccin gr. 1-2, given four times a day and gradually pushed up to a point 
just below the toxic, and held there for weeks or months. The writer 
would suggest a trial of this combination in all this group of infectious 
maladies for which as yet no remedy has been found, and which are so 
frightfully fatal. There is all to gain and nothing to lose. 



200 ANTHRAX 

ANTHRAX 

Anthrax is caused by a bacillus, non-motile, rod-shaped, sometimes 
jointed, from 2 to 25 micromillimeters in length. They multiply by fission 
and form dense networks. One variety produces spores, the other does not. 
The bacilli are easily destroyed but the spores sustain boiling temperature, 
or prolonged immersion in 5 per cent phenol solution. They resist gastric 
juice. 

Anthrax is prevalent among cattle and sheep in Asia and Europe, but 
rarely in America. Cases occurring in this country among men are mainly 
or exclusively in tanners. The writer had two cases in Philadelphia workers 
on goat-skins. The protective vaccine introduced by Pasteur it is hoped 
will extinguish the malady. In animals the infection is conveyed by insects, 
or by feeding in fields where animals have died of the disease or have been 
buried. All animals seem to be liable to anthrax, the herbivora most. 
Man is infected through the skin, lungs or stomach. Men who are about 
animals are most likely to become infected, in countries where anthrax 
prevails; in the United States morocco dressers are most exposed. 

Symptoms: — Malignant pustule is most frequent on exposed parts of the 
body. The local symptoms are much like those attending vaccination. 

After slight irritation and itching a papule appears, which becomes a 
pearly vesicle, umbilicated, with a narrow red margin rather than an areola, 
the base of the vesicle if exposed being black. A zone of brawny induration 
forms around this, with edema, the lymphatics form red lines leading to 
their glands, which become swollen. Fever follows rapidly, but soon falls 
below normal. The induration is so great that if on an arm the circulation 
is stopped, and the pain resembles that of a tight boot. Gangrene may 
ensue from interference with the blood-supply. If recovery follows the 
symptoms subside, the center sloughs out, and the glands return to a normal 
state. But death is apt to come inside of a week, the patient dying of 
prostration and sepsis. 

In malignant anthrax edema affects the eyelids, head or extremities. 
There is no papule or vesicle but extensive edema, with gangrene, spreading 
over much surface, and invariably death. Enteritis, peritonitis or endo- 
carditis may attend. The mind is clear throughout, but the patient may 
be crazed by fear if he comprehends his condition. The mortality from 
external anthrax is about 26 per cent in cases affecting the head or arms, 
5 per cent if the feet are attacked. 

The diagnosis is made by the occupation of the patient, his exposure, 
the vesicle with black base, and is confirmed by bacteriologic tests. 

When infection is received through the stomach we have symptoms of 
intense poisoning, chill, vomiting, diarrhea, some fever, pain in the calves 



HYDROPHOBIA 201 

and lumbar region. In the a cuter forms there are dyspnea, cyanosis, 
restlessness, anxiety and muscular spasms. Convulsions may occur. 
Mucous hemorrhages are seen, and petechia:. The spleen is congested. 
The blood is dark and fluid after death. If a number of persons eat 
infected flesh or drink the milk of infected cows, there will result a limited 
epidemic. 

Wool-sorters' disease occurs in the large establishments where imported 
wool and hair are picked over. Infection occurs from dust swallowed or 
inhaled. The attack begins with a chill, faintness, prostration, pain in 
the back and legs, and fever rising to 103 . There is pain in the chest 
with rapid breathing, cough, evidences of pulmonary congestion,weak and 
fast pulse, vomiting and signs of collapse. The system may be over- 
whelmed by the attack and death result in a few hours. If the case is 
prolonged there may be delirium and intense cerebral symptoms or coma, 
intestinal irritation or pneumonia. 

Rag-pickers' disease is a pulmonary anthrax with similar general 
symptoms. Severe general symptoms may attend external anthrax. 

The diagnosis of these internal forms must be made by the bacterio- 
logist. The occupation and sudden access point to this malady. 

Treatment: — In external anthrax the actual cautery should be applied 
as quickly as possible, followed by powerful local disinfectants. The 
obstruction to the circulation may demand long and deep incisions. Intern- 
ally the need is for the most powerful means of arousing the vital forces 
and sustaining them. The disease runs a brief course and if life can be 
retained for a week, there is a chance for recovery. 

Ipecacuanha has been advised in doses of gr. 5 to 10 every four hours, 
but for what reason is not stated. Pilocarpine in full doses might be 
tried — gr. 1-6 hypodermically. When anthrax germs have been swal- 
lowed the intensity of the attack may be lessened by prompt emesis and 
catharsis. Beyond this little hope exists in any internal form. 

The writer was attacked with anthrax in Africa in 1875, an( ^ recovered 
under the use of tincture of iron and aromatic sulphuric acid, a teaspoon- 
ful of each every four hours, in alternation, 

HYDROPHOBIA 

Hydrophobia or rabies is a disease principally affecting dogs, but also 
wolves, foxes, skunks and any other animals, including man, to which 
it may be communicated by the bites of those affected by it. 

The period of incubation is unknown and exceedingly variable. As 
no specific organism has as yet been isolated, it is exceedingly difficult 



202 HYDROPHOBIA 

to accurately diagnose this disease, in man or in animals, from other 
maladies for which it is frequently mistaken. Youatt, the celebrated 
veterinarian, did not believe in its existence, and allowed himself to be 
bitten by supposedly rabid animals many times, with impunLy; but 
finally was seized with dread that he might be mistaken, and committed 
suicide. Zuill doubted the existence of the disease, saying he had never 
met a case; and as to the symptom usually adduced of its presence in the 
dog, the presence of dirt, sticks, and similar trash in the stomach, said he 
never examined a dog dying of any disease or killed experimentally, without 
finding such material in the stomach. These things should at least make 
us cautious of accepting the diagnosis of rabies without sufficient proof. 

Horsley says the incubation is shorter in children than in adults; and 
when the wound is on an uncovered part of the body, especially the face; 
varying with the extent, depth and severity of the wounds and the animal 
inflicting the bite, the wolf being worst, then the cat, the dog next and other 
animals last. In man the period varies between two weeks and three 
months, and unestablished claims are made for incubation extending 
over a year or two. 

Symptoms: — During the premonitory stage there may be some irrita- 
bility of the wound, or numbness; mental depression, apprehension, 
hyperesthesia, congestion of the larynx, hoarseness, some fever and accel- 
erated pulse. Much of the mental disquiet is undoubtedly suggestive — 
the man who has been bitten by a mad dog has reason to feel apprehensive. 

Hyperesthesia increases till it is extreme; restlessness grows, reflex 
spasms are aroused by the slightest causes, the muscles of the face and 
throat are the seat of distressing spasms, dyspnea is severe, and an effort 
to drink excites spasm of the larynx, which arouses dread of water — 
hydrophobia. Delirium may occur of maniacal type, the mind being 
clear in the intervals. The temperature rises usually but may be sub- 
normal. This stage endures from 36 to 72 hours. 

The paralytic stage supervenes, coma comes on, the spasms cease, 
and the patient dies by syncope within a day. This stage is alone mani- 
fested in rodents, where it is termed dumb rabies. 

Anatomy: — Leucocytes accumulate around the vessels and nerve 
cells, especially the central motor ganglion cells — the rabic tubercles of 
Babes. Lymphoid and endothelioid cells gather around the sympathetic 
and cerebrospinal ganglionic nerve-cells. The latter degenerate. The 
virus abounds in the cord, brain and nerves, but is absent from the liver, 
spleen and kidneys. 

Treatment: — All bites of animals should be quickly cauterized with 
the agent most quickly available. Bleeding should be encouraged. Such 



HYDROPHOBIA 203 

agents as silver nitrate which simply burn a thin pellicle on the surface 
are unsafe; better use concentrated lye, which penetrates deeply. 

No treatment has yet availed to produce a single well authenticated 
cure. It has been asserted that pilocarpine has cured, and this may be 
tried. Many cases popularly believed to be rabies are really septicemia, 
mania, or altogether autosuggestive, induced by intense fear of the disease, 
which is fully capable of inducing symptoms thought by the patient to 
pertain to true rabies. Hence the stories of patients barking like dogs, 
etc. Sometimes it is impossible to separate these from true cases of 
rabies, especially when the animal that bit was killed in obedience to a 
popular delusion, that "if the dog ever goes mad all persons ever bitten 
by him will also become rabid." Such cases are so much more frequent 
than true rabies that only its occurrence in infants enables us to believe 
there is truly a human infection with this malady. 

Pasteur found the malignity of the virus increased when it was passed 
by successive inoculations through a series of rabbits; then that by pre- 
serving the spinal cords of the rabbits in dry air the virulence lessened, 
so that in about two weeks inoculations with it did not kill. By successive 
inoculations with fresher cords this immunity was established even against 
the most virulent preparations. This method he applied to the treatment 
of persons who had been bitten by rabid animals. Figures show that of 
13,817 persons thus treated at Paris the mortality was 0.5 per cent, or 69 
in nine years, or over 7 annually. This is about the average yearly mor- 
tality before the Pasteur treatment was instituted, whereas if all those 
inoculated were saved from rabies the deaths should have been over 1,500 
per annum. 

There are still some unresolved nebulae in the Pasteur theories; as, 
for instance, how it comes that as many persons die of rabies as ever, 
notwithstanding the inoculation of thousands. And why is it there were 
not thousands of deaths from rabies before these inoculations were made, 
if all who were bitten and escaped were saved by this method? 

Nevertheless the weight of evidence favors the Pasteur method, so 
much so that it is our duty to compel patients bitten by animals known 
to be rabid to have recourse to the method as quickly as possible — the 
efficacy of the treatment diminishing with each day after infection. 

When rabies has developed, if pilocarpine fails, there is nothing to 
do but keep the victim easy with chloroform by inhalation until death 
comes to his relief. 

In Ziemssen's Cyclopedia the reader will find an excellent article on 
this disease, giving all the delusions, like Marochetti's vesicles, which 
continually reappear in the lay press, though long since exploded. 



204 TETANUS 

Burggraeve advised to prevent accessions by the use of strychnine 
and quinine arsenate; for nervous spasm giving atropine, hyoscyamine, 
cicutine and camphor monobromide; for fever aconitine, veratrine and 
digitalin; giving the granules successively, one or two every half -hour 
according to the strength of the symptoms. It must be remembered that 
remedies are to be given till the desired effect is secured, no matter how 
high the doses soar above the maximum of the books. It will be observed 
that those who become familiar with this method of dosage soon become 
more optimistic in regard to prognosis than while practising in the ancient 
manner. The bounds of the possible and the probable are removed by 
methods made available by the use of certainties in therapy — and how 
far, is as yet not determined. 

TETANUS 

Tetanus is due to infection — generally of a wound — by the tetanus 
bacillus. This inhabits earth and manure. The disease occurs also in 
new born children from infection at the navel — tetanus neonatorum. 
This was very prevalent in Brazil, where it was the custom to cut the 
umbilical cord close to the placenta, and coil it up on the abdomen with 
ointments, where it was left to decompose. Two-thirds of the new-born 
infants died of tetanus. In one of the Hebrides this malady killed a 
majority of infants within two weeks of their birth, until people were 
taught to dress the cord with iodoform, which put an end to the com- 
plaint. 

Sometimes tetanus prevails in military hospitals, though less often 
than when the cause was unknown. Some years since there was a large 
crop of cases following a Fourth of July celebration, due to wounds 
from toy pistols, and fragments of copper caps, these lesions being espe- 
cially apt to be infected. A number of cases have followed vaccination, 
the virus being pure, but germs entering the open sore with dirt from the 
streets, when not properly cared for. 

The disease sometimes occurs in a wound, from sleeping on damp 
ground. It is not uncommon among horses, and men employed about 
stables are especially liable to contract it. 

The tetanus is a slender rod that may extend into a thread. A spore 
may occupy the swollen end. It is anaerobic, motile, and grows at ordi- 
nary temperatures. It remains in the immediate neighborhood of the 
wound and there secretes its toxin (tetanotoxin) but does not enter the 
circulation. It has been transmitted to animals which developed the 
disease. The poison is a toxalbumin, the most potent known, over ioo 



TETANUS 205 

times stronger than strychnine. It causes all the symptoms of tetanus 
when introduced without the bacillus. The symptoms develop so slowly 
that it is suggested that the bacillus undergoes some modification in the 
body before becoming active. It lives in the soil and in the bowels of 
herbivora, and has been produced by inoculating with infected earth. 
Immunity has been produced by injection of cultures, whose virulence 
has been diminished by the addition of iodine trichloride. 

Anatomy: — Congestions, perivascular exudations and granular changes 
in the nerve cells, no lesions of the centers. About the wound the nerves 
may be inflamed, red and swollen. In infants the navel is inflamed. 

Symptoms: — These should develop within tw r o weeks of the injury. 
The first evidences are stiffness of the neck and jaws, difficulty in masti- 
cation, sometimes preceded by rigors. The stiffness increases until 
typical lockjaw results — tonic spasm, with sardonic grin, the spasm extend- 
ing to the back, causing opisthotonos. In children it may be confined 
to the head and facial paralysis may attend. If the entire body is rigid 
the state is known as orthotonos; if drawn to a side it is right or left pleuro- 
sthotonos; while if bowed to the front it is termed emprosthotonos. The 
spasms may be so powerful that the muscles are ruptured. Affecting 
the respiratory apparatus asphyxia may result. Spasms of intenser con- 
traction occur, with partial relaxation intervening. Continually slighter 
irritations induce the spasms — a breath of wind, the touch of the sheet, 
the opening of a door. They occasion frightful suffering in the con- 
tracted muscles. Speech may be impossible, and cold sweat covers the 
face and body. The temperature may be low until shortly before death, 
when it rises to hypeq^yretic heights, even to no° F. Death may occur 
from asphyxia, heart-failure, or exhaustion. There is a chronic form, 
the symptoms at first less marked, the course less rapid. Complete inter- 
missions occur, which become more prolonged. Relapses are common. 

In Rose's head-tetanus, the cause is an injury of the side of the head, 
the symptoms being confined to that side of the head and face, with dys- 
phagia. 

Prognosis: — This is bad in proportion to the acuteness of the symp- 
toms; 90 per cent of acute cases and 25 per cent of chronic die. It is 
worse in children. Good omens are a late attack, absence of fever and 
spasms limited to a part. 

Diagnosis: — The most similar affection is poisoning from strychnine, 
but in this the lockjaw comes late, while in tetanus it is an early symp- 
tom. Tetany is too feeble an affection to be mistaken for tetanus; the 
former occurs in hysterics, and is confined to the hands, occurring at 
intervals of w r eeks and relaxing promptly when a few drops of any anes- 



206 TETANUS 

thetic are inhaled. In rabies the reflex respiratory spasms predominate, 
psychic disturbance is marked, lockjaw absent. 

Treatment: — The localization of the bacilli about the wound indicates 
the necessity of extirpating them there, by excision or cauterization. This 
should be thorough. Absolute quiet in a cool, dark room is of import- 
ance. Food may be administered by the rectum or vagina, the most con- 
centrated and nutritious foods being employed by enema, or on tampons; 
or fed through a soft catheter inserted into the pharynx through the nose. 

Chloroform by inhalation and morphine by hypodermic should be 
given to full effect of affording relief. Ordinary doses make no impression 
at all on the terrible pangs. All the benefit accruing to anodynes will be 
secured from these better than from weaker and more doubtful agents. 
Anders thinks he saved one patient by hypodermics of strychnine and 
digitalis. 

Is there any curative drug? Many have been tried, and succeeding 
in some milder cases have been unduly vaunted, only to fail when tried 
in severe forms. Quinine in doses of ioo grains was extolled by a Vir- 
ginian physician, but failed in one case where it was suggested by the 
writer. Of all agents within his knowledge he would expect most from 
pilocarpine by hypodermic . in full doses, enough to cause free sweating 
and relaxation. 

The results from antitetanic serum are not very encouraging. The 
effects are too slow in developing, unless the serum is injected into the 
meninges — a procedure not without its dangers. Veterinarians have 
employed it successfully to arrest the spread of tetanus in infected stables, 
as a prcphylactic. One case was reported in the Alkaloidal Clinic in 
which it was successfully employed thus for a child who had been wounded 
but had not yet showed any evidences of tetanus. In view of the slight 
proportion of wounds that develop this malady, the practice does not 
seem justifiable — the injections being made in the meninges after trephin- 
ing. Behring urged that his serum should be given not more than 26 
hours after the beginning of the attack. Large and repeated doses are 
required. Out of 96 cases collected by Stintzing 35 died. 

Baccelli suggested hypodermic injections of carbolic acid, one to two 
drams of a \ per cent watery solution along the spine. The testimony as 
to this method is contradictory but on the whole quite favorable. When 
the dose mentioned failed much larger ones were employed and some 
successes followed; but afterwards reports of failure with exceedingly large 
quantities of the acid were published. 

The patient may have already passed beyond the possibility of cure, 
however, and in such matters a single patient rescued from certain death 



MEDITERRANEAN FEVER 207 

should outweigh many failures. In the only instance in which the acid 
was employed in the writer 's experience recovery ensued. Nietert reported 
a recovery after 99 grains had been injected during the first 24 hours and 
267 grains during the treatment. 

Curarine has been advised as it directly antagonizes the peripheral 
sensory hyperesthesia. But as this is simply a manifestation of the 
toxemia, and curarine does not eliminate the toxin, there seems little use 
in smothering the symptom when the damage is still continuing. The 
patient does not die from the hyperesthesia but from exhaustion. This 
objection applies as well to all remedies for non-essential symptoms. 

Sufficient attention has not been given to excision of the tissues about the 
wound, in which the toxin-secreting bacteria are collected. 

In International Clinics Stevens quotes 26 cases, exclusive of Vallas' 
6, treated by antitetanic serum, of which 10 were failures. Bearing in 
mind the tendency to report only favorable cases, this is significant. Letulle 
urges the Calmette method of treating wounds likely to occasion tetanus: 
Wash with boiled water 15 minutes, dust thoroughly with dried powdered 
antitetanic serum, and cover with gauze. 

MEDITERRANEAN FEVER 

This malady is known as Malta fever. It prevails especially on that 
island and along the Mediterranean, also in the West Indies where we meet 
it in Porto Rico, and in the Philippines in the East. Possibly its range is 
wider but it has been confounded with typhoid and malaria 

The onset resembles that of typhoid — lassitude, anorexia, bone-ache, 
headache and malaise. These increase till the patient ceases to work and 
remains in bed. The headache has become intense, with constipation and 
thirst. The tongue is coated, stomach sore, throat red. Cough and 
roughness at the base of the lungs indicate congestion. There may be 
nocturnal delirium. The fever resembles typhoid, rising during the day 
and sinking at night, with free sweating toward morning. The spleen and 
liver are enlarged. Pain in the back may be distressing. 

This attack may last a week or more, when improvement sets in and 
appetite returns. Fever, weakness and sweating remain, with anemia 
but better sleep. Then the patient begins to feel rheumatoid pains shifting 
from joint to joint till the whole system may have been affected. Neuralgias 
and orchitis may complicate. 

The fever may gradually climb for ten days to 104 , then subside as 
slowly, with a range like the first week of typhoid. In most cases apyrexia 
is followed by another rise, and this may go on for months. The fever may 
remit, intermit or be nearly continuous. 



208 WEIL'S DISEASE 

The motality is about 2 per cent, but it leaves anemia, rheumatoid pains 
and neuralgias that are distressing. Death may result from sudden hyper- 
pyrexia, from pneumonia, or exhaustion. There is no pathologic anatomy 
except the large, soft spleen with numerous lymphoid cells. In it is found 
a peculiar organism, the micrococcus Melitensis discovered by Bruce, 
which is but rarely detected in the blood. Injections of pure cultures have 
imparted the disease to monkeys. The parasite is flagellated (Gordon.) 

This fever is most common in persons between the ages of 6 and 13. 
Acclimatization does not confer immunity. It is most common in the 
drier seasons. It haunts certain houses. Bad water and fecal infection 
are blamed. It is not contagious. Incubation lasts from 6 days to 17. 
Bruce held it to be self-protective but others claim an attack increases 
liability to others. 

The diagnosis from typhoid is at first difficult, being based largely on 
the absence of distinctive typhoid symptoms, and the occurrence of arthritic 
pains and sweating, the history of the presence of either, and the Widal test. 
The germ of Malta fever reacts more markedly than that of typhoid. Even 
the prognosis is indicated by the test, being bad if agglutination remains 
low or falls from a high point to zero. If a high reaction falls much a long 
course is to be expected. 

Treatment: — Prevention teaches the avoidance of affected places in the 
warm months; and care as to the purity of drinking water. The rules of 
municipal and personal hygiene are simple and too well known to warrant 
repetition. Begin with calomel, follow with salines, and employ cold 
sponging to keep the temperature below 103. Manson condemns quinine 
and salicylates, and doubts the advisability of coal-tars in such a disease 
of prolonged debility. The treatment is symptomatic. It is to be hoped 
that the principles of intestinal antisepsis may be applied in this malady 
by those who comprehend them and have the opportunity. 

The food should be light — milk, broth, eggs, liquids as long as fever 
remains and until the tongue has been clean for 10 days. Lemonade is 
useful after the first period. Flannels should be changed when wet with 
sweat. Change of residence is not specially advisable. 

WEIL'S DISEASE 

An acute infection fever with jaundice, described first in 1886. Most 
cases occur in summer, in groups, especially in butchers. Lanphear has 
described cases occurring in this country. It is more frequent in males 
between 25 and 40. 

The attack is abrupt, with chill, headache, backache, and leg-ache 
as usual in acute infections; but there is often a severe pain in the cheeks 



BERI-BERI 209 

which is peculiar to this affection. The fever is remittent. The spleen and 
liver are enlarged. Jaundice occurs early, usually with acholic stools. 
The stomach and bowels arc not affected much. The urine is albuminous, 
sometimes containing blood. Delirium and coma are occasional symptoms. 

The course runs from ten days to two weeks. There is no distinctive 
anatomy known. Jaeger claimed the malady was due to a proteus infection. 

The treatment as yet is to be conducted on general principles — calomel 
and saline to empty the bowels, sulphocarbolates enough to disinfect them, 
aconitine to allay fever, cardiac tonics to sustain vitality, possibly diovi- 
burnin or boldine as specific for the hepatic condition; rest, quiet, mild 
easily digestible and nutritious food, avoiding fats, and giving bile or cholic 
acid to compensate for the failure of the liver and prevent the consequences 
sure to arise from the absence of bile from the bowels. If the liver is very 
tender a blister or hot water bottle over it should be of use. Depleting the 
portal system by enemas of glycerin or of concentrated salt solution may 
prove of value. 

BERI-BERI 

The acquisition of the Philippines and our growing interests in the East 
render this affection of possible interest to us. It is a multiple neuritis, 
occurring frequently in Japan. It has been found among Massachusetts 
fishermen, and in he asylum at Tuscaloosa, Ala,, also at the State Asylum 
at Little Rock, Ark., in 1895. Possibly were its features better known more 
cases would be recognized. 

Some believe beri-beri to be caused by a specific microorganism, as yet 
unidentified. It spreads from foci, attacks young and robust persons, 
prevails at certain seasons, and has spread as an epidemic. While not 
believed contagious it seems to be transported from place to place. In 
Japan it is attributed to a diet too exclusively of rice, or to bad rice; and 
great improvement has followed the addition of nitrogenous articles to the 
diet. Kisagi forbids fresh fish, to which some have attributed the malady. 
From one-fourth of the strength of the Japanese navy being subject to 
beri-beri, the disease has by these changes in diet been extinguished. In 
Java it has ceased when unshelled rice was substituted for the shelled. 
Bad hygienic conditions and residence in damp places predispose to beri- 
beri. Males are more liable, especially men between 16 and 25. 

Symptoms: — In one class of cases the most prominent symptom is 
paralysis of the lower extremities, motor and sensory, affecting also the 
fingers and isolated areas on the arms and trunk with anesthesia. The 
calves are thin, muscles tender, giving the reaction of degeneration, reflexes 



210 BERI-BERI 

at knee and ankle absent, deep reflexes lost but superficial present except 
in advanced cases, ataxia and weakness, no tremor, rarely any implication 
of muscles of the head or neck. The sphincters and detrusors are normal 
but dyspepsia and distention after eating are common. The gait is ataxic 
with real muscular weakness added. The toes may drag so that the patient 
walks with a "string-halt. " The urine is normal, digestion fair, eliminants 
active; in fact the general condition is remarkably good except for peripheral 
neuritis. 

The heart's impulse is diffused or obscured by effusion in the peri- 
cardium. There is pulsation in the epigastrium and of the carotids. 
Jugular pulsation shows tricuspid regurgitation. The dull area is widened 
to the right. A systolic murmur is present, with a double second sound. 
The interval is shortened. Slight exertion causes rapid heart-action. 
Vascular tension is relaxed. The cardiac signs vary from time to time, 
showing the difficulty to reside in the innervation. 

In another form the cardinal symptom is dropsy. Anasarca is universal, 
the face cyanotic, the urine scanty and dark. Little or no albumin is to be 
found. Pressure causes less pitting than in nephritis. The edema may 
be local and transient, and infrequently involves the scrotum. The heart- 
symptoms resemble those described above. Effusion may take place into 
the pleura. Dyspnea prevents exercise. Reflexes are weak and absent; 
the shins and finger tips anesthetic. Digestion is good but there may be 
pain and tenderness in the stomach. Manson attributes' the dropsy to 
alteration of the nerves governing urinary excretion and osmosis in connec- 
tive tissues. 

In a third group the two forms are variously commingled. Fever is not 
a feature of either form. 

Cases present all grades of severity, and distribution, of symptoms. 
Much difficulty is experienced in diagnosis by those not familiar with the 
protean aspects of beri-beri. Filarial are sometimes found in the blood as 
an accidental complication. Other parasites are detected in the stools. 

The cases generally will be found to come from some center of the disease 
which supplies several typical forms and mixed cases, and from these the 
atypic may be detected and c'assified. 

The attack may be sudden or insidious; the course rapid or slow. 
Malignancy may supervene at any time upon milder forms. It may subside 
in a short time, and relapses occur. Complete recovery is usual but 
muscular atrophy or organic heart-disease may remain. Unexpected 
recovery from most threatening forms and sudden death in mild cases are 
not unusual. The heart may fail at any time. 

The paraplegic cases are known as dry, the dropsical as wet beri-beri. 



BERI-BERI 211 

Etiology: — Both sexes are liable, all ages except the extremes, all occu- 
pations are affected but a sedentary life predisposes, and asylums and jails 
are frequently invaded. Pregnant and puerperal women are especially 
liable. The plethoric are not immune. Hot weather favors the disease, 
and the rainy season. It clings to localities like malaria, especially if wet 
and hot, and affects persons sleeping near the ground. All depressing 
conditions favor its outbreak. It does not shun the city like malaria, and 
often appears among the crews of ships. Overcrowding with poor venti- 
lation has a distinct influence in developing the disease if the germs are 
present. It does not seem to be contagious, or directly infective, but it 
may become implanted in a hospital offering the requisite heat, dampness 
and overcrowding, and then nurses may be affected. Since patients 
improve at once when removed from their bad surroundings, Manson 
attributes the malady to a toxin generated by a germ inhabiting the place 
rather than the patient's body. It is therefore a sapremia, or the germs 
in the body soon die and the disease ceases unless fresh germs are continually 
introduced. The improvement following the addition of nitrogen or fat 
to the diet may be explained as lessening the suitability of the body as a 
field for the cultivation of the as yet undiscovered germ. 

The condition found at post mortems is degeneration of the distal 
ends of the peripheral nerves. There may also be atrophy of muscular 
fibers of the heart and elsewhere, dilatation of the right cardiac cavities, 
with great accumulation of blood in them and the veins; serum in the 
connective and great serous cavities and often pulmonary edema. 

Death most frequently occurs from complication of the cardiac nerves, 
sometimes of the pulmonary. Dilatation is the most dangerous condition 
arising. Anything pointing to heart-weakness or disease is of bad omen. 
Very scanty urine is bad, also large serous effusions, and paretic implication 
of the muscles of respiration. Vomiting is considered a fatal prognostic 
in Japan. Dropsy is more dangerous than other forms; more die in low 
places than in elevated, and the acuter cases are more to be feared. The 
mortality varies in different epidemics from 30 to 5 per cent. 

Diagnosis: — Ordinarily the diagnosis is easy — multiple peripheric 
neuritis is beri-beri when epidemic or endemic. Edema over the shins 
especially distinguishes it from alcoholic neuritis, as does the heart-affection. 
Rheumatism is not a tropical disease, the altered reflexes and tender calves 
are not rheumatic. In the natives of tropical lands all pareses, edemas, 
cardiac affections and rheumatic pains are possibly beri-beri. 

Treatment: — Remove the patient from the infected place at once. 
Select a dry locality and put him at the top of the house, in a well-ventilated 
sunny room. Feed well, with plenty of nitrogen and little bulk. Substitute 



212 MILK DISEASE 

wheat, barley or oatmeal for rice. Milk and eggs are useful, with plenty 
of fat. If the heart is notably affected confine the patient to bed. Other 
cases should be in the sun and air. In dropsical cases limit the fluids taken 
and give salines. Heart-tonics seem useful — digitalin or strophanthin. 
Glonoin may be needed for acute dyspnea or failing heart. It should be 
ready for emergencies, as well as amyl nitrite for still more imminent 
danger. It may be necessary to bleed to relieve the overburdened heart. 
Serous effusion may require aspiration. Faradization and massage are 
useful for the mucsular affection. Strychnine, arsenic and silver are then 
of use as tonics. Take care to avoid deformity by contractures. Relapses 
are to be prevented by shunning sources of reinfection. Sea voyages are 
very beneficial. Patients recover if removed to healthy places. 

If the malady appears in an institution it is to be emptied at once and 
inmates removed to high and dry quarters. The hygienic conditions 
must be remedied if the premises are to be again utilized. When the 
disease appears on a ship, ventilation, drying, removal of bilgewater and 
rotten wood, are to be enforced, with removal of the sick to the open air 
and revision of the diet. Disinfectants are advised, but it is well to say 
little of them, the tendency being strong to rely on scattering about a lot 
of phenol and neglecting everything else. But fumigation with burning 
sulphur is useful as destroying all germs in clothing and other articles 
that might escape ordinary disinfecting. 

MILK DISEASE 

In the Mississippi Valley and the eastern slopes of the Alleghanies 
there has prevailed a disease of cattle known as the trembles. It affects 
newly settled localities and disappears as the forests are cut and the soil 
brought under cultivation. The animals may show no sign of the malady 
unless over-driven, but their products are nevertheless toxic. The sick 
cow refuses food, staggers, her eyes are injected, her muscles tremble, 
and she has convulsions. 

To man the disease is communicated by the flesh, milk, butter. and 
cheese from affected animals. The poison is not destroyed by cooking. 
It is fatal also to dogs. Evidently this is not a bacterium or protozoan 
but a fixed poison acting chemically. Probably it is due to some plant 
that is eaten by the cow, but which is exterminated or loses its toxicity 
when clearing and cultivation become general. 

In man the symptoms are uneasiness and gastric trouble lasting some 
days; then vomiting and pain in the stomach begin, with fever and thirst. 
Constipation is obstinate. The tongue is swollen and tremulous, the 



FOOT-AND-MOUTH DISEASE 213 

breath bad with an odor said by Graff to be distinctive of this disease. 
There may be marked cerebral involvement, restlessness, coma, convulsions 
and delirium. Death may occur in two days, or after the symptoms have 
run into a typhoid state. It may drag along for a month. 

Treatment: — Empty the stomach and bowels at once to get rid of any 
remains of the toxic material, sustain the strength; promote elimination; 
quiet fever and restlessness. 

FOOT-AND-MOUTH DISEASE 

There are still a good many dark corners in medicine, and not a few of 
these might be cleared up were we to turn into them the light obtained 
from the study of disease of animals. The present day sees the problems 
presented by malaria and yellow fever solved by a study of the mosquito. 
The spread of typhoid fever by the housefly, of tuberculosis by the bedbug, 
of plague by the fleas appertaining to rats and dogs, are more or less 
established. The diseases of animals, especially the domesticated beasts, 
transmissible to man, have been studied from one side or the other; but as 
yet the facts elicited by the physician of human beings and the modern 
veterinarian have not perhaps been correlated as closely as they might be. 

The malady in question affects cattle, sheep, pigs and other domestic 
animals. It is an acute affection that spreads with unexampled rapidity. 
The period of incubation is less than five days. The attack begins with 
fever, and little vesicles appear on the mucous membrane of the mouth, that 
enlarge and ulcerate. The animal wastes rapidly. The disease appears 
also upon the udders, the milk becomes yellowish and mucoid in 
consistence. 

To the human species the infection is conveyed by the milk, and hence 
children are the usual sufferers. Milk products, such as butter and cheese, 
also convey the infection. It causes fever, diarrhea and vomiting, an 
eruption of the intertrigo type, and an aphthous deposit on the mucous 
membrane of the mouth and pharynx. Hemorrhages are common in 
some epidemics, of which some are quite fatal, though the mortality averages 
about 8 per cent. Filters of unglazed porcelain arrest the passage of the 
smallest microorganisms known, but the virulence of the vesicular lymph 
remains after passing through these filters (Loeffler.) The flesh of affected 
animals is not believed to carry this infection, and it seems likely that heat 
destroys it. If this be so, the milk may be rendered harmless by boiling. 

The only treatment suggested by the text-books on medicine is the 
application of powerful germicides, as strong as the tissues will bear, and 
frequently repeated. No special agent has been shown to be best suited 



214 GLANDULAR FEVER 

to this affection, but saturated salicylic acid solutions, and lactic acid, 
have proved useful in other aphthous conditions. 

The strength of the patient should be carefully maintained by judicious 
feeding and suitable tonics. So far the books carry us. Limiting them- 
selves to measures that have stood the test of time, anything experimental 
would naturally be excluded from their pages. But as there is nothing of 
any value in their limits, we are perforce driven to let the patient get through 
the best way he can, unaided, or to use some of the methods as yet on trial. 

Some of us have learned to credit pilocarpine with a remarkable power 
of combating certain forms of invading microorganisms, and especially 
the smallest known forms, such as the micrococci. The control exerted 
by this alkaloid over erysipelas has scarcely a parallel in established thera- 
peutics. Those who have employed pilocarpine in scarlatina report results 
little inferior. Its effects in foot-and-mouth disease might wisely be 
investigated. A dose of this agent sufficient to cause slight sweating or 
salivation may be given, and the action sustained by cumulative dosage. 
The control exerted over boils and other forms of suppuration by calcium 
sulphide has long been known. 

The prognosis is largely influenced by the strength of the patient's 
resistance against the invading disease. 

What is the best local antiseptic for application to the aphthous patches ? 
Lactic, benzoic, boric and salicylic acids; chlorine, iodine, bromine; 
iodoform and its congeners, europhen, aristol, and iodol; peroxide of hydro- 
gen; the volatile oils; resorcin; phenol, lysol, tricresol; the corrosive salts 
of mercury, silver, iron, copper, zinc, cadmium; arsenous acid; and this is 
not a complete list by any means. One or other of these must be better 
than the rest — which is it ? 

Bad hygienic surroundings determine malignancy in all the group of 
infectious fevers as affecting mankind — is this equally true as regards 
animals similarly affected, or does continued contact with such morbific 
agencies beget immunity ? 

GLANDULAR FEVER 

In 1889 Pfeiffer called attention to this malady as a distinct form of 
acute infectious fever. It occurs in children, especially between five 
and eight years of age. It may occur as an epidemic. The specific cause 
has not been ascertained. 

Glandular fever commences with pain and consequent stiffness of the 
neck; nausea, vomiting, pain in the bowels, fever moderate, some sore- 
ness of the throat, with swelling of the tonsils which soon subsides. Inside 



GLANDULAR FEVER 215 

of three days swelling occurs of the cervical lymphatic glands, those behind 
the sterno-cleido-mastoid especially; also the inguinal and axillary glands 
in many cases. The mesenteric glands, spleen and liver are often enlarged. 
Sometimes the glands are enormous. They are tender, and may be 
surrounded by puffiness of the connective. There is no catarrh attending. 
Suppuration, hemorrhagic nephritis, otitis media and retropharyngeal 
abscess have been reported as happening in some cases. The fever passes 
off in a few days but the glandular swelling may persist for weeks. 

The writer has met several cases of a similar disease in adults, one 
case occurring in a woman of 26 years. The posterior cervical glands 
were swollen and tender, there was slight fever with malaise and ano- 
rexia, and the superficial glands all over the body were similarly affected. 
Small doses of iron iodide were followed by iodism to a degree the writer 
had never witnessed. The swelling of the subcutaneous glands was 
nowhere larger than a pea. It persisted several weeks and passed away 
gradually. 

Treatment: — No treatment has as yet been demonstrated as useful, 
but the general rules of treating fevers are applicable here. The well- 
known power of phytolaccin to dissipate glandular inflammations renders 
its use here advisable; all the more since the less useful and objectionable 
properties of that other gland stimulant, calomel, have been advised. 
What it can do, phytolaccin can in this case do better. Give a child gr. 
1-6 every hour till nausea or softening pulse denote saturation; then every 
two to four hours. 



PART II 

CONSTITUTIONAL DISEASES 



AUTOINTOXICATION 

The theory of autointoxication was firmly held by our ancestors, whose 
initial treatment of all inflammatory affections consisted in emptying 
the alimentary canal and freeing the emunctories, besides relieving abnor- 
mal vascular pressure. The reaction that commenced with Graves' feed- 
ing fevers carried the entire depressant medication away, and it is only 
in recent times that anyone has had the courage to assert that the accep- 
tance of new theories as to pathology does not carry with it as a necessary 
consequence the desertion of methods of treatment that have proved 
successful. The explanation given of the modus operandi of these may be 
erroneous, but it does not follow that the therapeutics is therefore worthless. 

The elimination of toxins remained, however, as a cardinal principle 
in the practice of the masses of active clinicians, despite the rise and spread 
of the supportive idea; and when anew proclaimed by Bouchard with 
Gallic vividness it found a ready response. An examination of its merits 
was in fact forced on the profession, and the result has been that such 
convincing facts were developed that the truth of the principle has become 
too apparent to be ignored. This theory and its application in the treat- 
ment of fevers are fully discussed elsewhere; we will limit ourselves here 
to a presentation of the topic in general, discussing first the case as pre- 
sented in the monograph by Von Noorden. 

His work is based on toxins that have actually been isolated and their 
origin and effects determined. The work is by no means complete but 
enough has been done to show that there is a solid chemical basis for 
the doctrine of autointoxication. 

Acid Products of Metabolism:— In breaking up and rearranging pro- 
teids, fats and carbohydrates, certain acid intermediary bodies are formed, 
that undergo further alterations or are excreted; carbonic acid free by the 
lungs, sulphuric, uric, phosphoric, hydrochloric acids in combination, 
by the kidneys. The alkali is supplied by the food, the sodium of the 
blood and potassium of the cell protoplasm. Reduction of the alkaline 
reaction of the body entails serious consequences. In the dog when the 



218 AUTOINTOXICATION 

food alkali is reduced the nervous system becomes deranged and assimi- 
lation disturbed, death finally resulting, with spasms. The cause is sul- 
phuric acid intoxication (Bunge), produced by proteid catabolism. 

When the administration of acids is pushed the alkali is lost more 
rapidly, in herbivora; respiration becomes more rapid at first, then slows; 
the pulse is faster, vascular pressure rises, both falling off later; the ani- 
mals become ataxic, have spasms and die in coma. Carnivora are pro- 
tected by their superior power of generating ammonia which protects 
the fixed alkalies. Man shares this advantage. Similar evidences are 
recognizable clinically when the blood alkali is reduced, and acids with 
ammonia are excreted far in excess of the normal quantities. 

Acids may accumulate if their excretion is reduced or their formation 
increased above their elimination. Clinical importance attaches to the 
increase of acid formation with defective elimination. The acids con- 
cerned are sarcolactic, carbaminic, aliphatic, oxalic, uric, aromatic oxy-, 
and especially beta-oxybutyric, diacetic, and acetone; the latter three 
being known as the acetone bodies. Their chemical relations may be 
shown by the following: 

Beta-oxybutyric acid: CH 3 — CHOH— CH2— COOH. 
Diacetic acid: CH— CO— CH2— COOH. 
Acetone: CH3— CO— CH2. 

The first is oxidized into the second, which forms acetone and carbonic 
acid on being warmed. The occurrence of acetonuria is therefore to be 
attributed to a peculiar interference with oxidation, and the appearance 
of oxybutyric acid indicates a higher degree of such interference. Acetonu- 
ria is a form of general acid intoxication, and the acetone acids are no 
more toxic than any other acids. Some acetone is excreted during health, 
more during fasting; and if this is prolonged the other acetone bodies are 
also excreted. If the food is limited to proteids and fats the same thing 
occurs, and the acetone bodies only cease to appear in the urine when 
carbohydrates are administered. Their excretion is also increased by 
feeding with fatty acids, as in butter, provided the carbohydrates are 
excluded. 

The acetone bodies are now looked upon as intermediate products of 
metabolism, which owing to the absence of carbohydrate food are not 
consumed, producing carbonic acid and water. The acetones are formed 
in the cells, somewhere, possibly in the liver, the carbohydrates acting as 
preventive by affording oxygen in nascent form, or furnishing necessary 
intermediates, since there is no lack of respiratory oxygen when acetones 
are produced. 



AUTOINTOXICATION 219 

In the experimental acetonuria of phloridzin and pancreatic diabetes, 
the acidosis of human diabetes, febrile acid intoxication and the crypto- 
genetic form of these intoxications, the acetone formation is attributed 
to poisons formed in the intestinal canal (Kraus). Von Noorden does 
not consider this assumption necessary, attributing all acetonurias to ihe 
perversion of carbohydrate digestion and assimilation. The excretion 
of acetone bodies is to a certain extent proportional to the height of the 
fever, but it subsides rapidly when the quantities of carbohydrates in the 
food are increased (Hirschfeld). The same conclusion has been reached 
as to carcinomatous acetonuria. These facts deprive acetonuria of much 
of the prognostic significance formerly attributed to it. 

There are, however, some other factors influencing the appearance of 
acetonuria when the carbohydrates are withdrawn — the individuality of 
patients exerts a marked effect, and those who are accustomed to use but 
little carbohydrates bear their complete withdrawal better than others 
who have been accustomed to the freer use of these articles. 

It follows that in all non-diabetic acetonurias the first principle of treat- 
ment is to add a supply of carbohydrates to the diet, five ounces a day 
sufficing in any case, according to Von Noorden. If, as in severe gastro- 
enteritis, it be necessary to ingest this food by the veins or subcutaneously, 
dextrose or levulose must be employed since the disaccharides are only 
disintegrated in the alimentary canal. The free administration of salines 
neutralizes the acids and at the same time eliminates these toxins from the 
body. 

Bouchard calls seriously in question the prevalent overvaluation of 
vicarious elimination. The removal of water from the body does not 
necessarily carry out with it a proportional quantity of toxins. While 
1,000 grams of urine remove 15 grams of urea, 1,000 grams of sweat 
only remove 0.30 gram; and the same proportion holds good for the 
bowel. The skin eliminates water with a little salt, carbonic acid and 
volatile fatty acids. Perspiration is useful in some poisonings by elimi- 
nating not the poisons but some of their products. But pilocarpine 
sweat contains five times the normal proportion of solids. The lungs 
eliminate water, carbonic acid, sometimes ammonia, fatty acids, and 
volatile poisons accidentally swallowed. The kidneys eliminate every- 
thing except gases — water, two-thirds of the solids excreted, many nitro- 
genous substances. 

In nearly all diseases death is caused by asphyxia, and this by intoxica- 
tion. The urinary poisons of two days and four hours kill the average 
man. Bouchard found in the urine seven toxic substances, of which 
urea was least injurious. Potash and an unknown body cause convul- 



220 AUTOINTOXICATION 

sions, others give rise to narcotism, salivation and mydriasis, and one 
lowers the production of heat. These toxins are supplied by the tissues, 
the secreting organs, foods, and the decomposition of fecal elements. 
Part of the toxicity may be removed from the urine by fixing that of the 
intestine, by charcoal. Bouchard objects to soluble antiseptics, as they 
lose some power before they reach the large bowel, and by entering the 
blood may exert there a noxious influence. But neither of these is neces- 
sarily true, and in dealing with each agent we may ask whether either 
objection applies to it. Abundant experience with the sulphocarbolates 
shows that neither applies to them — ^they surely disinfect the bowel and 
the stools, and they do not cause any evil by being absorbed into the 
blood, even when given in doses far above what are usually required to 
disinfect the bowel. 

Whenever the progress of the fecal mass is arrested, decomposition 
of some sort commences, and some of the resulting toxic matters are 
absorbed into the blood. The effects of this hemic contamination may 
be shown in any part of the body, since the blood carrying the toxins to 
every part, the most impressible or least resistant tissues will react most 
evidently against the irritant. Hence we may have an infinite variety 
of phenomena rather than any distinct clinical picture. Perhaps the 
most common evidences are headache, dullness and sluggishness of mind 
and body, apathy and morbidity, the "blues," itching and other irrita- 
tions of the skin, anorexia, bad breath, aggravation of preexistent catarrhs, 
and in fact the whole complex usually attributed to "uricacidemia." 
In fact, it is now understood that since uric acid is non-toxic the pheno- 
mena assigned to this form o r autotoxemia are in whole or great part due 
directly to fecal retention and absorption. The perspiration may become 
offensive, the eyes heavy and conjunctiva muddy, the skin pimply and 
unhealthy, the urine strong and dark. 

The effects of fecal autotoxemia form a field as yet unexplored, and 
we can only indicate them in a general manner. The kidneys, liver, 
lungs and skin aid in eliminating the toxins, and disorders of either or 
all these eliminations may follow in time. The continued effect of an 
empoisoned blood-supply on the tissues can not fail but prove baleful, 
and we may have here the explanation of chronic maladies of the delicate 
tissues of the spinal cord, and of other organs. At any rate, such toxica- 
tion lowers the vital resistance and renders the body at large and the 
tissues of the points of lowest vitality more liable to microbic invasions. 

When the various toxins recognized by Bouchard have been isolated 
and studied scientifically we may assign to each the morbid phenomena 
for which it is responsible, and trace the toxin to its source. Scarcely 



DIABETES MELLITUS 221 

a suggestion has yet been given to the possibility of such studies, and 
the only intimation of differentiation is the remark that mercaptan is 
the cause of melancholy. There is most probably a specific toxin that 
causes itching, and the presence of pruritus ani may direct attention to 
fecal retention and this toxin formation. But the special effects of indol, 
skatol, and other already recognized toxins, have not been fixed 
definitely. 

Treatment: — Empty the bowels, disinfect them, keep them from filling 
up again, and regulate the diet and personal hygiene. 

An evening dose of podophyllotoxin followed by a morning saline may 
be alone required; or it may demand a week or more of careful treat- 
ment, medical and mechanical, to fulfill the first indication. 

Disinfection is not superfluous; no matter how well the cathartics 
have acted there is a distinct gain from chemical disinfection, such as is 
obtainable from the sulphocarbolates. 

It is usual to meet the dietary indication by restricting the intake of 
nitrogenous foods; but this is simply because we can smell the toxins 
emitted by their disintegration, and several containing nitrogen have 
been isolated. The diet must be regulated to supply — and not over- 
supply — the patient's needs, and his powers of digestion. The injunc- 
tion, hurriedly dropped as an afterthought, to restrict meat, makes little 
impression on the patient; lay down the law positively and tell him just 
how many ounces of meat he may take each day. The more carefully 
the directions are given, the better they will be obeyed. 

The same holds true as to exercise, bathing, work, etc. Study each 
case by itself, apply the regimen indicated, but be ready to alter it wherever 
it proves a misfit. 

To prevent the bowel filling up, involves the treatment of dilatation 
of the stomach and paresis of the colon, and these are considered in their 
proper place. 

DIABETES MELLITUS 

Diabetes is a chronic affection in which glucose is excreted in the urine. 
The urine shows traces of sugar to the most delicate tests at all times. 
Transitory glycosurias occur in several diseases, and an excess of carbo- 
hydrates in the diet may occasion it in a healthy man; but these are not 
diabetes. Neither are the excretion of lactose by nursing women, nor 
the occasional appearance of pentoses, glycuronic acid and levulose. 

Pathology: — Diabetes has been ascribed to pancreatic disease, supra- 
renal excess, interference with the glycogenic function of the liver, microbic 



222 DIABETES MELLITUS 

action, deficiency in the conversion of fat by the protoplasm of the intes- 
tinal villi, etc. 

Normal human blood contains i-io per cent of sugar, loosely com- 
bined, which may escape if too plentiful or if the kidneys become perm- 
eable to it. Combined with lecithin it forms jecorin (Drechsel), and 
Kolisch attributed diabetes to the loosening of this union. Phloridzin 
is a diuretic, stimulating the renal epithelium, and producing glycosuria, 
probably by decomposing proteids. Nephritis diminishes glycosuria in 
all forms. 

The true cause is increase of the sugar in the blood, which may even 
reach 10 per cent. The hyperglycemia at first corresponds to the glyco- 
suria but increases as the case progresses. 

Puncture of the tip of the calamus scriptorius causes glycosuria, con- 
tinuing till the glycogen of the liver and muscles is exhausted. Nervous 
irritation may occasion transitory attacks and influence the course of any 
form. When the food CH exceeds the storage capacity of the liver and 
is not converted into fat, the surplus appears as glycosuria. At one meal 
he system can assimilate 150 to 200 grams of glucose, 120 of milk sugar, 
150 of levulose, on an average. Cane and milk sugars in the urine indi- 
cate a lack of ferment in the bowel, not excess of glycogen in the liver. 
Maltose is converted into glucose, and those who can not do this have 
glycosuria after indulgence in beer even if other carbohydrates do not 
cause it. The assimilation of pentoses is very low. 

To test the assimilation of glucose, adminster 100 grams in water on 
rising, and test for sugar; none appears in the urine of healthy persons. 
It may appear in traumatic neuroses, cerebral and meningeal inflammations, 
menta" disorders such as mania, and in paralysis, fevers and alcoholism. 
These may be explained by passing irritat'ons of the nerve centers or 
disorder of the pancreas. Alimentary levulosuria indicates hepatic in- 
sufficiency. 

Most of the phenomena may be explained as due to failure of the 
tissues to form glycogen, the d'etary CH being exerted by the kidneys. 
But exercise does not lessen the glycosuria, actually increasing it except 
in slight cases. Levulose being more easily assimilated than other carbo- 
hydrates lessens glycosuria and increases glycogen storage. The presence 
of levulose in the urine when not ingested or any CH is used is a 
bad omen. 

Etiology: — Destruction of the pancreas causes glycosuria, slight if 1-5 
of the gland remains, but diverting the pancreatic secretion from the bowel 
does not cause it. This leads to the theory that diabetes results from the 
loss of an internal pancreatic secretion, which stimulates glycogen formation 



DIABETES MELLITUS 223 

or checks its destruction. Fat formation may proceed, causing obesity; 
or fail later, superadding diabetes; or be deficient from the first, 
causing diabetes without obesity. The tissues take sugar from the 
blood and the deficiency is supplied automatically by the liver, 
from the food CH, and when this is cut off, from the proteids; 
casein contributing most, then legumin, egg-albumin and cereals least. 
Of fats, glycerin and lecithin supply sugar, the fats of the body being 
utilized, not those of the food. 

The formation of acetone bodies is fully considered in the article on 
autointoxication. When all the CH and most of the proteids eaten appear 
in the urine as sugar, the excretion of acetone indicates the intensity of the 
diabetes. When acetone excretion reaches 4 decigrams a day, diacetic 
acid appears; when it reaches a gram a day, oxybutyric acid will be excreted. 
The odor of acetone will appear on the breath. In mild cases the system 
acquires the power of disposing of these bodies, but if severe their excretion 
rises to a gram a day, and the slower this declines the worse the prognosis. 
If the decline will not begin until CH is added to the diet the outlook is 
ominous. The daily excretion of acetone and diacetic acid may rise to 6 
grams, but that of oxybutyric acid may even reach 80 grams. But even 
when the excretion is great and the danger corresponding, life may be 
prolonged for years. When the acids cannot be neutralized by the ammonia 
formed from proteid foods, the fixed alkalies of the body are drawn upon, 
nutrition suffering. As the supply of these fail, the acidemia occasions 
coma. The administration of alkalies postpones this for a time, but the 
acetone salts are toxic. 

Etiology: — Diabetes is hereditary, more frequent in males, usually 
beginning after 35 and before 60, is more common among the rich, and 
especially Jews, neurotics, brain workers with sedentary habits, the obese, 
syphilitics, cachectics in general, and is increasingly prevalent in France 
and India. It has quickly appeared after nervous shocks and strains, or 
acute infectious fevers, and during pregnancy. Some cases occurring in 
man and wife have seemed to indicate contagion, but the similarity of habits 
and other causes may account for these. 

Symptoms: — The course is exceedingly variable, the beginning is 
unknown, the early symptoms uncertain. At first glycosuria appears after 
excesses, occasionally, and may not become continuous for years. Many 
times it is accidentally revealed by an examination for life insurance. 
Transitory glycosuria indicates an abnormal liability to the malady, and 
the wisdom of regulating the diet. The usual history is of progressive 
debility, emaciation, cutaneous irritability, neuralgia, weak sight, cramps 
in the calves at night, thirst and frequent and copious micturition. Slight 



224 DIABETES MELLITUS 

exertion causes fatigue, the temper becomes irritable, and impotence may 
occur early. The usual treatment gives little relief. The sugar is detected 
in the urine. Men who urinate in the open are apt to present white sugar 
spots on their trouser ends. 

The course is rarely acute. Headaches are common, with indigestion, 
the appetite becoming greater as the waste increases. The urine may 
increase till gallons are voided daily. It is pale, the s. g. up to 1050 but 
usually near 1030, the odor sweetish, acid, the sugar daily lost amounting 
sometimes to a pound, urea increased, ammonia also, and sometimes the 
phosphates. Slight albuminuria is common at first, grave nephritis 
develops late, interstitial, with arteriosclerosis, etc. Gases may form from 
fermentation in the bladder. The great thirst and appetite may occasion 
gastric dilatation. The bowels are usually constipated, the tongue dry 
and rough, gums unhealthy, teeth decay, saliva acid and contains sugar. 
The liver may enlarge. Cutaneous symptoms are pruritus, general or of 
the vulva, balanitis, eczema, skin dry and harsh, the hair falls, the nails 
sometimes also, boils, carbuncles, gangrene especially of the feet, and edema. 

The approach of coma may be indicated by drowsiness, mental fog, 
digestive disorder, irritability of the stomach and readiness of mental or 
bodily fatigue on slight exertion. The drowsiness suddenly deepens, 
respiration quickens, the pulse becomes fast, and coma may end in death 
within 36 hours. Coma may also develop suddenly after unusual exertion, 
or acute infections, alcoholism, or anesthetization. 

The demand for food is increased by the want of assimilation, stomach 
but not tissue hunger being satisfied. The excess of nitrogen taken adds 
to its excretion but the tissue proteids are better protected than in healthy 
persons. The blood serum may contain fat in excess of the normal 1 per 
cent, derived from food and the tissues. Assimilation is defective from 
the lack of lipase, the fat ferment. 

When methylene blue is added to diabetic blood the blue color is reduced 
to a yellowish red. Diabetic blood smears treated with methylene give a 
pale green. (Williamson-Bremer reaction.) 

Peripheral neuritis is common, causing ataxia, anesthesia, sometimes 
perforating ulcer of the foot. The deep reflexes may be absent. Cataract 
is not uncommon, and other ocular and aural affections may be seen. 
Gastric crises occur, with colic, fever and vomiting. Occurring in pregnant 
women, the fetus is apt to die or premature delivery occur, the diabetes 
being worse after labor. The temperature falls below normal as the malady 
progresses. Emaciation may be masked by fat, or edema. 

Diabetes of severe type may occur in infancy, milder in childhood. 
Occurring with pancreatic disease, fatty stools do not appear. 



DIABETES MELLITUS 225 

Prognosis: — Acute cases may terminate in a few days or weeks. The 
older the patient when attacked, the slower the course, and the milder 
the symptoms. The obese bear the malady better than the lean. But the 
best results follow early recognition and skilful treatment, with patients 
obedient and capable of self-control. Too great severity will be followed 
by certain dietetic excess, with recurrences each more difficult to control, 
and the development of secondary maladies, degenerations, arteriosclerosis, 
neuroses, ocular affections, loss of teeth, etc. Gangrene appears in cases 
mild and chronic but neglected. The object of treatment is complete and 
permanent suppression of the glycosuria. When this is secured the toler- 
ation of carbohydrates rises gradually so that more can be assimilated 
without glycosuria appearing. These are " cured" though they are liable 
to recurrences. 

Cases may be classed as severe when the glycosuria does not cease 
when CH is absolutely excluded from the diet, and even limiting the proteids 
may not succeed; also if not more than 50 grams of bread a day can be 
assimilated. Such cases rarely establish a tolerance for larger quantities, 
and what they have is lost. Acute infections lessen the assimilative power, 
at least temporarily. Severe forms are incurable and we seek only to check 
the progress. Even with large loss of sugar and constant acidosis life may 
be prolonged for years. Coma is bad — 80 per cent of severe cases die 
of it; 3 per cent of gangrene, the others of intercurrent maladies. Of mild 
cases 5 per cent die of coma, over 20 per cent of gangrene. 

Innutrition is one of the chief dangers. Nuclein destruction is a second, 
acidosis a third in severe cases, and the lessened resistance renders inter- 
current affections more fatal. Wounds of diabetics do badly and necrosis 
is frequent. The skin is very vulnerable, phthisis is common, old age 
comes prematurely, neuroses and arterial affections are common. 

Diagnosis: — This is made by study of the causes, the gradual onset, 
with progressive debility, impotence, symmetrical sciatica, cataract, boils, 
increase in micturition, and persistence of. sugar in the urine. The dietetic 
and methylene tests have been mentioned. 

The authors have not deemed it desirable to give the methods of test- 
ing the urine for the presence of sugar, the limits of this work forbidding 
them. These matters are treated in text books on chemistry. 

Prophylaxis: — This maybe applied in families where diabetes is hered- 
itary, and when transitory glycosuria appears without being preceded by 
the excessive use of sugar; such patients should be advised to limit the use 
of carbohydrates, closely limiting that of sugar or abstaining from it 
altogether. The urine should be frequently examined, and not the morning 
urine but that taken from the entire day. Excess of carbohydrates lessens 



226 DIABETES MELLITUS 

the power of assimilating them; restraint in their use increases assimilation; 
otherwise the ordinary rules of personal hygiene apply. 

Etiological Treatment: — Neurogenous glycosuria is transitory but may 
be a precursor of diabetes; it should therefore be a signal for prophylaxis. 
It aggravates true diabetes, however, therefore pains should be taken to 
avoid disturbances. It is not an indication for removing the limitation 
of carbohydrates. The surroundings of the patient should be regulated 
so as to avoid such disturbances as will affect him injuriously. 

Syphilis may cause glycosuria, or neurogenous glycosuria may develop 
in syphilitics; while antisyphilitic treatment will not rebuild tissues that 
have been destroyed, it may stop the progress of the disease in so far as the 
latter depends upon the syphilis. Diabetics are very sensitive to mercury, 
and it should be used with the utmost caution. 

Pancreatic extracts have been recommended on the theory that the 
disease is due to a lack of pancreatic secretion. As to the diabetes proper, 
these extracts exert no beneficial effects; but they do aid in the digestion of 
fats, and prevent disturbances arising from insufficient pancreatic action 
in the intestines. Croftan has advised the use of mixed extracts of pancreas 
and muscles. Thyroid and suprarenal extracts seem to aggravate glycosuria; 
liver extracts have proved useless. The triumphs of organotherapy in 
diabetes lie still in the future. 

Direct Treatment: — Opium has been long used. If full supplies of 
carbohydrates be allowed, opium is useless; but when the glycosuria has 
been reduced to its lowest point by deprivation of carbohydrates, opium 
will cause the last of the sugar to disappear. Von Noorden says that 
codeine is as effective as opium without being constipating. He gives 
from 2 to 2\ grains of either each 24 hours. Diabetics bear opiates well, 
becoming accustomed to them after a few days. The action of opium 
here is not understood; it may cut off the neurogenous and alimentary 
glycosuria. Hare claims that opium itself is more effective than codeint 
or morphine and since Von Noorden states that the same weight of opium 
is as effective as codeine, it seems evident that there is a curative 
principle in opium besides the powerful hypnotics. It would seem there- 
fore, that there is room for a useful investigation of the numerous other 
active principles found in opium, as obviously any one of them that would 
prove efficient in diabetes without the disadvantages inseparable from the 
hypnotic principles would be of inestimable value. This very obvious study 
has yet to be made. 

Of the salicyl derivatives, Von Noorden gives the first place to aspirin 
as it interferes least with the digestive organs. It is best suited to cases 
least amenable to opium; that is, slight cases, when the use of carbohydrates 



DIABETES MELLITUS 227 

is permitted. This remedy increases the power of assimilating carbohy- 
drates, without increasing the glycosuria. The average daily dose of 
salicylic acid is 45 grains. The benefit is not uniform in all cases. Anti- 
pyrin has a similar but less decidedly beneficial action. Salicylic acid 
should not be used continuously, as it loses its beneficial influence, nor 
when the kidneys are diseased; but the salicylates and antipyrin are contra- 
indicated by gastric disorders. 

In some cases jambul lessens glycosuria markedly for a few weeks, 
when its good effects cease. No case of cure has yet been credited to this 
remedy. Von Noorden recommends jambul and salicylic acid to be 
occasionally given for three or four weeks, when analysis shows that they 
lessen the glycosuria and increase the assimilation of carbohydrates. The 
diet should be strictly maintained at the beginning of the jambul treatment, 
small quantities of carbohydrates being introduced while it is being taken. 
All other drugs recommended as specifics for diabetes, including arsenic, 
cacodylates, strychnine and uranium, are condemned by Von Noorden as 
worthless. He devotes some attention, however, to the good results 
produced by faith in quack remedies, diabetics being a credulous people. 

Many patients resort to health resorts, among which may be mentioned 
in Europe, Carlsbad, Vichy, Neuenhar and Homburg. The benefit is 
partly suggestive, largely due to the regimen. Temporary relief also 
follows the use of the alkalis which all these waters contain. Removal 
from stress and strain, with rest and outdoor exercise, careful regulation 
of the diet and the skill which comes from experience in the management 
of minor details, explain much of the relief following a visit to these resorts. 
The waters also may benefit complications ; but there is nothing miraculous, 
or even mysterious in the benefit there obtained. 

Dietetic Treatment; — If the glycosuria can be stopped for some time, 
without injury to the patient, the power of assimilating carbohydrates 
increases; if the glycosuria persists, this power decreases; it may decrease 
in spite of the best treatment, but it always declines more rapidly if dietary 
precautions are neglected, while degenerations continue. The most 
important point as to diet is the limitation or deprivation of carbohydrates. 
We have, however, to consider the appearance of acetone, the effect on the 
digestive organs, the general health and strength and the nervous system. 
The practical application of the diet therefore must be suited to the case. 
The treatment must be devised to suit the man, since the man was not 
constructed to suit the treatment; but in all cases the object must be the 
reduction of glycosuria to the smallest possible limit. 

We begin by ascertaining how much carbohydrate the patient can tolerate. 
For this purpose Von Noorden devised a test diet. Foods are divided into 



* 2 8 DIABETES MELLITUS 

two groups, the principal articles which are practically free from carbo- 
hydrates, and accessory articles which contain the latter. His standard diet 
is as follows: Breakfast: 200 grams coffee or tea, with one to two table- 
spoonfuls of thick cream; 100 grams of hot or cold meat, as weighed after 
cooking; butter; two eggs with bacon; 50 grams of white bread. 

Lunch: Two eggs cooked as desired without flour; meat, boiled or 
roasted; fish, venison or fowl, weighing when cooked 200 to 250 grams; 
vegetables, spinach, cabbage, cauliflower or asparagus, prepared with 
broth, butter or other fat, eggs or thick sour cream, but no flour; 20 to 25 
grams creamy cheese, Camembert or Brie, plenty of butter; two glasses 
of white or light red wine if desired; one small cup of coffee, with one or 
two tablespoonfuls of thick cream; fifty grams of white bread. 

Dinner: Clear meat soup, with egg or green vegetable in it; one to 
two meat dishes as at lunch; vegetables as at lunch; salad of lettuce, 
cucumber or tomatoes; wine; no bread; other drink during the day 
one or two bottles of aerated water. 

The total urine excreted during 24 hours is collected, the day and 
night separately, and examined quantitatively for sugar; the excretion 
of acetone, oxybutyric acid, ammonia and nitrogen is also ascertained. 
If on this diet no sugar is excreted, the bread is gradually increased until 
sugar appears, when the bread is diminished. Changes are not made too 
rapidly for a proper estimate of their effects. If the glycosuria subsides 
while bread is still being taken, we are dealing with a slight form, and 
have ascertained the toleration of the patient. When the sugar only ceases 
when bread is totally excluded, we have the severe form. In each of 
these there are many grades. In most extreme cases, glycosuria continues 
when carbohydrates are totally excluded and proteids largely reduced. 

We next study the influence of rest and of exercise, finding wide differ- 
ences in various cases. The time at which carbohydrates are taken has 
its influence, some tolerating them later but not in the morning; others 
take carbohydrates better in small and frequent doses, while others do 
better by taking the whole quantity at one meal. Some patients tolerate 
some carbohydrates better than others — milk or fruit sugar better than 
starch for instance; oats or potatoes better than rye or wheat. The in- 
fluence of drugs, alcohol and mineral waters is then to be ascertained. 

In all slight cases the carbohydrates should be excluded for two or 
three weeks; by this means the toleration rises and degenerations are 
checked. Carbohydrates are then to be added gradually in accordance 
with the knowledge gained by our study of the case, the quantity always 
being kept below the limit of toleration. The rule must be imperative 
that no more glycosuria can be permitted in future. From time to time 



DIABETES MELLITUS 229 

the patients should abstain from carbohydrates for a week or two, the fat 
being increased to avoid debility; daily weighing is advisable to keep the 
process in due control. Loss of weight ought not to exceed one pound a 
week. 

Nervous people not only bear this closely restricted diet well, but re- 
quire it more imperatively than do other cases; the nervous symptoms 
are markedly relieved by it. In albuminuria the restriction period should 
not exceed three weeks; the proteids and extractives should not be ex- 
cessive. The albuminuria often increases for a few days and then sinks, 
sometimes permanently disappearing. The appearance of acetonuria 
does not contraindicate rigid abstinence from carbohydrates. In a short 
time the acetonuria subsides; if, however, it becomes excessive, the diet 
must be modified and some carbohydrates permitted. Such cases should 
be treated in institutions. The individual question is so important 
that the diet lists of foods forbidden and permitted should be 
disregarded. 

In severe cases 80 to 100 grams of bread is allowed daily and the pro- 
teids reduced until not over fourteen grams of nitrogen appear in the urine; 
after every fourth to sixth week, an eight-day or ten-day period of fully res- 
tricted diet should be enjoined. Careful attention should be paid to the 
reaction of the various proteids and carbohydrates. Meat should be re- 
stricted to 200 grams a day as weighed after cooking; egg and vegetable 
albumens are much better tolerated. Soon after beginning the restricted 
diet course, for two or three days the proteids are reduced to the utmost; 
abundance of alkali is then administered to prevent acidosis. Daily analy- 
ses are made of the urine. Longer periods of restriction should only be 
attempted in an institution until we have ascertained the effect of shoner 
periods on the general health, the glycosuria and the acetonuria. Enormous 
advantages, are gained by restricting the diet for two or three weeks; but 
although the dangers of acetonuria are much exaggerated, the closest 
watch must be held over this symptom. After such a period of restriction 
we may allow 80 to 100 grams of the carbohydrate best tolerated to be con- 
sumed as best tolerated; the proteids must be held permanently low enough 
to restrict the renal excretion of nitrogen to 12 or 15 grams daily. This 
diet must be frequently interrupted by two or three days of complete ab- 
stinence from carbohydrates. This is to be regulated by the effect. Once 
or twice each year the longer period of restriction should be enforced with 
due precaution. 

The question of sending patients to Carlsbad, or prescribing longer 
periods of restriction, is always an individual one, to be answered by ob- 
serving the effects of shorter periods. 



230 



DIABETES MELLITUS 



Von Noorden accidentally discovered that some patients did well on 
the free use of oatmeal gruel, 200 to 250 grams of oatmeal being given 
every two hours, with 200 to 300 grams of butter, 100 grams of vegetable 
proteid or a few eggs in addition. Nothing else was allowed, except 
black coffee or tea, lemon juice, wine or a little liquor. After three or 
four days this is followed by one or two "vegetable days". It is well to 
precede this treatment by a few days of restricted diet or one or two "veg- 
etable days.' ' At hrst the glycosuria increases, but in a few days diminish- 
es, and the acetonuria even more so. The urine is nearly or entirely free 
from sugar, the results being better than those following complete re- 
striction. The toleration of carbohydrates rises. These results, however, 
occur in but a few cases, but these were very severe forms, many occurring 
in children or young people. In slight cases the method always failed. 
Neither meat nor other carbohydrates can be allowed during the oatmeal 
treatment. Edema occasionally develops, but ceases when the oatmeal 
is discontinued. 

Similar results have been asserted as following the exclusive admini- 
stration of rice, of milk, and of potatoes. In some cases potatoes do bet- 
ter than the oat cure, but the latter suits more cases. The principle, how- 
ever, of limiting the carbohydrates to one particular variety, at the same 
excluding meat, underlies all these methods. Some persons seem able 
to assimilate one carbohydrate better than any other. When we are for- 
tunate enough to discover one such article as the patient can take with im- 
punity, we have eliminated the dangers of acetonuria from that case. 



I. 


EQUIVALENT TABLE FOR WHITE BREAD. 


Article 


Percentage of Car- 
bohydrate 


20 Grams of White 
Bread Represents 




Rye Bread 


About 50 per cent 
" 45 

70 " 


24 grams 


Graham Brown Bread . . . 
Triscuit (Natural Food 
Co.) 


26 " 1 
17 " 




II. SPECIAL BREAI 


)S FOR DIABETICS. 



White bread 

Black bread 

Zwieback 

Oat cakes 

Graham bread 

Almond bread (Dr. Lam- 
pe ) 



30 per cent 
38 " 
45 
-65 
28 



40 grams 
32 " 
26 " 
18 " 
45 " 



The numbers give the 
average of numerous es- 
timations. 



III. PARISIAN BREADS FOR DIABETICS. 



Soya bread 


14.4 per cent 


1 


80 grams 








IV. 


COCOA. 




Pure cocoa powder 


30 per cent 


1 


40 grams 



V. NATURAL FLOURS AND MEALS. 



Wheat, rye, barley, oat 
maize, buckwheat, 
millet 

Beans, peas, lentils 

Soya beans 

Gluten meal 



75 to 80 per cent 
38 " 
48.5 " 
7 " 



is grams 
20 " 

as " 
170 " 



DIABETES MELLITUS 



2U 





VI. STARCH FLOUR. 




Article 


1 Percentage of Car- 
bohydrate 


20 Grams of White 
Bread Represents 




Irom potatoes, wheat, 
tapioca, rice, sago, 

maize, mondamin . . 


82 per cent 


14 gram^ 






VII. PREPARED MEALS. 





Vermicelli 

Macaroni . 

Vermicelli, macaroni for 
diabetics 



80 per cent 
80 

55 



1 5 grams 
15 " 







VIII. 


CEREALS. 




Oats 

Rice 

Barlev 




60 per cent 

70 

66 




20 grams 

17 " 

18 " 








IX. 


PULSES. 






Peas, lentils, beans 

Peas, beans, broad beans 


S3 per cent 

30 


23 grams 
40 " 


Dried seeds. 

In fresh condition. 






X. 


TUBERS. 






Potatoes (summer) 

Potatoes (winter) 

Celery 


16 to 18 per cent 
20 " 22 " 
12 




70 grams 
100 " 
100 " 








XL FRESH FRUITS. 





Sweet cherries 

Sour cherries 

Mullxjrries 

Apples 

Pears 

Strawberries 

Gooseberries (ripe) . . 
Gooseberries (unripe) 

Black currants 

Apricots 

Peaches 

Raspberries 

Bilberries 

Blackberries 

Cranberries 

Pineapples (very sour) 
Spanish oranges 



Spanish oranges 
Oranges 




100 to 200 grams 

120 " 130 " 

120 " 

150 " 
150 

240 " 

170 " 

500 " 

200 " 
300 
300 
300 

240 " 

3°o 

600 " 1200 " 

150 " 

900 " 



100 
120 
120 
170 

150 

150 
200 
200 
240 



600 " 



400 " 480 
200 " 240 



After cooking. 



Weighed, unpeeled, 
Jan. and Feb. 

Weighed, peeled, 
Jan. and Feb. 

March to May, 
chiefly laevulose. 



XII. 



About 4.5 per cent 
2.5 to 3 
About 4 

" 2-5 " 



MILKS. 

About 275 C c. 



Milk 

Sour cream 
Sour milk . 
Kephir 



400 to 840 
About 300 
" 480 



Numerous analyses. 



Table I. 

The following foods may be consumed by all diabetics in as large quan- 
tities as they may desire. If it be desirable, however, to limit the intake 
of proteids, the foods containing large amounts, such as meat, cheese and 
eggs, must be used sparingly if at all. Some diabetics cannot take spices. 

Fresh meats, muscular tissues of birds and animals, braised, boiled 
or roasted, with gravy, butter, meal or flour, mayonnaise, or other sauces 
without flour, warm or cold; tongue, heart, lungs, brains, calf's spleen, 
kidney, marrow, calf's liver, game and poultry, not to exceed 100 grams 
weighed after cooking; the feet, ears, snout and tail; dried and smoked 
meats, smoked and salted tongue, pickled meats, ham, bacon; canned 
meats and all sausages if free from flour; somatose, casein, meat extracts; 



232 DIABETES MELLITUS 

all fresh and salt water fish if served with sauce containing no flour or 
bread crumbs; dried, salted or smoked fish, pickled herrings, fish in oil 
and caviare; shellfish, lobster, crab, turtle, crawfish; Worcester and all 
other sauces; eggs; any animal or vegetable fats, pure cream, 
sweet or sour. 

None of the baked foods are free from carbohydrates. Gluten and 
almond breads are useful if carbohydrates can be excluded in their manu- 
facture. 

Fresh vegetables, lettuce, endive, cress, dandelion; aromatic herbs, 
leek, garlic and celery; gherkins, tomatoes, young green beans, vegetable 
marrow, onions, radishes, seakale; root artichokes in slight cases only; 
asparagus, Brussels sprouts, chicory, rhubarb, celery stalks; cauliflower; 
burr-artichoke; spinach, sorrel, cabbage, beets; fresh mushrooms; green 
gooseberries sweetened with saccharin; pickles, olives, sauerkraut; all 
spices; soups made with meats and green vegetables; desserts made 
from eggs, cream almonds, citron and gelatin, sweetened only with 
saccharin; all spring and seltzer waters; good liquors; any dry wine, such as 
Bordeaux, Burgundy, white Rhine and Mosel; tea and coffee with cream, 
but no sugar; a little cocoa if well boiled; lemonade sweetened with 
saccharin or glycerin. 

Table II. 

This table contains foods which have a very little carbohydrate. They 
are not permissible during strict dieting but are useful when we begin to 
relax and test the increase of toleration. The quantity of each one allowed 
must be prescribed. 

Vegetables cooked without sugar or flour. 

Dried beans or peas, a tablespoonful. 

White and red turnips, carrots, celery root. 

Canned peas and beans; 

Lima beans, two tablespoonfuls. 

A tablespoonful mashed or fried potatoes. 

Nuts up to 50 grams. 

French apples, pears or apricots, 50 grams. 

Raspberries, strawberries, black currants, a heaping tablespoonful. 

Wild raspberries or blackberries, two tablespoonfuls. 

Bilberries, three tablespoonfuls. 

Fruits cooked with saccharin and no sugar. 

Plums, apples, pears, apricots, peaches or sour cherries, a heaping 
tablespoonful. 

Black, goose, or raspberries, two heaping tablespoonfuls. 

Dried plums or peaches,when swollen with water,a heaping tablespoonful. 



DIABETES MELLITUS 233 

Milk, a deciliter(3 1-2 oz.). 

Levulose chocolate or cocoa, unsweetened, 10 grams. 

Foods rich in carbohydrates cannot be used at all during rigid dieting; 
as this is relaxed they may follow those in Table II, the quantities being 
dispensed by weight and the effect closely watched. We may give 100 
grams of white bread or its equivalent in other starches, using that form 
which each patient tolerates best. 

Dr. Heinrich Stern has recently in the Medical Record directed attention 
to two forms of gangrene occurring in diabetes. The idiopathic form is due 
to sclerotic disease of the blood vessels interfering with the circulation. 
This is a dry gangrene and should be kept dry; time should be al- 
lowed such cases under antidiabetic regimen to form a line of demarcation. 

The inflammatory gangrene results from the attacks of virulent 
microorganisms upon tissues vitiated by deficient nutrition and autotoxic 
processes. This occurs only in grave forms of the disease. In both forms 
the best prophylactic is the suppression of glycosuria; hygienic measures are 
important. The slightest elevation of temperature calls for immediate oper- 
ation, from which, however, little is to be expected where the vitality is 
so low and the septic condition so marked. 

Among the remedies which have been credited with more or less con- 
trol over the progress of diabetes are to be mentioned arsenic bromide, 
guaiacol, iodides, lactic acid, glycerin, glonoin, creosote, quinine, lithia 
salts and strontium lactate. Some of these act as intestinal antiseptics 
and the benefits resulting from such agents, while universally admitted, 
have not yet been determined accurately. Others relieve certain symp- 
toms or combat certain ill tendencies. The writer secured good results 
from strontium lactate in the earlier stages of the malady. It seems un- 
likely, however, that any specific will ever be found for this disease and 
that we must continue to treat the diabetic rather than diabetes. 



234 DIABETES INSIPIDUS 

DIABETES INSIPIDUS 

In this disease there is excessive thirst and corresponding urination, 
the urine being of low specific gravity and containing neither sugar nor 
albumin. No characteristic lesions have yet been noted; the enlargement 
of the kidney sometimes noted is as likely to be a result of the malady 
as a cause. The bladder, ureters and pelves of the kidneys may be dilated 
by distention. The quantity of fluid discharged through the urinary 
ways may be enormous. 

Etiology: — Among the causes have been noted nervous and phys- 
ical shock, or injury, lesions of the floor of the fourth ventricle and sixth 
nerve paralysis; acute infectious diseases; intemperance, especially of 
beer; hereditary influence; age, occurring in childhood and early youth, 
or even congenitally; most cases occur in males. 

Symptoms: — The disease may be termed a vasomotor neurosis, usuallj 
centric, sometimes reflex. Unless it follows shock the onset is gradual. 
The quality o^; urine excreted daily may reach sixty pints, the specific 
gravity being correspondingly low. The total excretion of solids is some- 
what increased; the thirst is incessant; the appetite little if at all increased 
The skin and mucosa are dry as in diabetes. The other secretions are 
scanty. Nutrition is well maintained. Remarkable tolerance of alcohol 
has been noted. Neurasthenia, insomnia and chorea are frequent. 

While most cases recover, the course is irregular. When death occurs 
it is from an intercurrent disease, or from the fatal character of the primary 
causal lesion. 

Diagnosis: — We do not find sugar or albumin as in diabetes mellitus 
and nephritis; hysteria has its numerous accompanying symptoms; no 
other disease shows the enormous thirst and urination with the character- 
istics of the urine above noted. 

Treatment: — The patient should be induced to restrict his drinking 
as closely as possible. The laws of personal hygiene should be applied 
in all respects. Pilocarpine in doses sufficient to cause perspiration has 
proved beneficial. Zinc valerianate usually controls nervous phenomena. 
A continuously astringent effect may be exerted upon the urinary tract 
by the administration of arbutin, gr. 1-6 every hour while awake; this 
we believe is better than the preparations of ergot; but there is no question 
that full doses of ergotin powerfully check the polyuria. 

Burggraeve recommended strychnine, 6 to 8 granules a day. 

Feilchenfeld reports that marked decrease in the quantity of urine 
excreted with specific gravity unchanged occurred after injecting strych- 
nine nitrate, gr. 1-25 to 1-12. 



ARTHRITIS DEFORMANS 235 

ARTHRITIS DEFORMANS 

A chronic progressive disease of the joints causing great disability 
and deformity. 

Pathology: — The cartilages are gradually absorbed from the center 
outwardly; the exposed ends of the bones become polished by friction 
with absorption; where there is little or no pressure, the cartilage is thickened 
and ossified, osteophytes locking the joints. The synovial membranes 
are inflamed and the exudation may become organized and even ossified; 
the ligaments are thickened and further restrict motion. Sometimes 
they relax, however, until dislocation is permitted. The muscles waste, 
the nerves may be inflamed. The intimate lesion consists in cell pro- 
liferation with softening and absorption or medullation of the cartilages. 

Etiology: — The nature of the disease is doubtful but it is neither rheu- 
matic nor gouty. There is some reason for attributing it to central nervous 
disease. Others blame it upon microorganisms, and Dor even repro- 
duces it in animals with cultures of the staphyloccus pyogenes aureus. 

Women are more frequently affected, sterility with ovarian and uterine 
disease having a decided influence. It has been attributed to nervous 
shocks, is most frequent between twenty and thirty years of age, is some- 
times hereditary, occurs in the poor rather than the rich, and may be 
induced by various infections. 

The majority of severe cases coming to the writer have been users of 
alcohol. 

Symptoms: — The malady usually begins in one hand, soon affecting 
the other and progressing, with periods of partial recovery. The joints 
enlarge and are rather painful on movement but without other symptoms 
of local inflammation. Other joints are gradually affected, symmetric- 
ally, until nearly every joint in the body has been disabled. The hands 
become misshapen in various ways, the joints stiffening until all move- 
ment may be lost. Crepitation occurs. The thumb may be unaffected. 
The hand is sometimes the only movable part of the body. The unused 
muscles atrophy and contract, causing further deformities. 

The course of the disease is variable; its progress may be arrested 
at any point and the general health remain good. It is perhaps significant 
that gastrointestinal ailments attend the progressive cases. The pulse is 
permanently rapid and respiration frequent. 

The disease may be limited to a single joint, usually the hip, forming 
morbus coxce senilis. It may follow an injury; or the disease may affect 
only the shoulder or knee, all these forms appearing in old men. Some- 
times it affects the vertebrae. Heberden's nodes are found in women 
past thirty, on the distal joints of the fingers; at first they are swollen and 



236 GOUT 

inflamed, the malady going on with temporary improvement until hard 
nodules are formed and the fingers become knobbed. 

An acute form occurs rarely, before the age of thirty. It follows 
puerperal conditions; the arthritis is multiple, the inflammatory symp- 
toms marked, with a good deal of swelling within the joints. A chronic 
affection in children described by Still shows progressive enlargement of 
the joints, the spleen and lymphatics. The inflammatory symptoms 
are marked, the course of the disease slow. 

Diagnosis: — In rheumatism the large joints are first affected; it changes 
from one joint to another and leaves no deformity, but a tendency to heart 
disease; in all these respects rheumatism differs from all forms of the 
malady under consideration. Arthritis of the shoulder joint sometimes 
occurs, with pain, infiltration of the ligaments, wasting muscles and some- 
times neuritis. It ends in recovery. 

Prognosis: — Rheumatoid arthritis does not seem to endanger life; 
sometimes cases improve and sometimes the progress of the malady 
stops. 

Treatment: — Anders recommends cod-liver oil and especially iodine 
and arsenic; the iodide of arsenic may be given, in doses of gr. 1-67, three 
times a day to an adult, increased until toxic action is evident in irritation 
of the eyelids. The doses should then be held as closely as possible to 
this point without actually touching it, and the remedy continued for 
many months. Dry hot air has, also been advocated. Banna tyne advised 
guaiacol carbonate pushed to and held at full toleration. Cold com- 
presses locally relieve acute symptoms, and with massage promote absorp- 
tion of debris. 

The most hopeful publication the writer has seen concerning the 
treatment of this disease, was a paper by Prof. Craig in The Alkdloidal 
Clinic. Prof. Craig and his wife were both victims of this malady. His 
treatment, which was very successful, consisted in keeping the bowels 
clear and aseptic, and restricting the diet closely, avoiding meat, all acid 
fruits and other acid foods. Since progressive cases are attended with 
disturbance in the stomach and bowels, it seems rational that we should 
there direct our principal treatment. 

GOUT 

Gout is now defined as a form of perverted nutrition, with the for- 
mation of uric acid and attacks of acute arthritis, sometimes with urate 
deposits. It is probable that there are present an excessive absorption 
of nutritives, disordered metabolism and defective elimination. 



GOUT 237 

Among the various theories concerning the pathogenesis of gout we 
may mention the following: Excess of uric acid (Garrod); by increased 
formation and less elimination, lessened alkalinity (Haig); excessive pro- 
duction of uric acid (Ebstein); precipitation of crystalline biurate of 
sodium (Roberts); tissue-necrosis from an assumed ferment (Von Noor- 
den); defective renal function (Klemperer); urate deposits in tissues less 
alkaline than blood (Morhorst); increase of xanthin bases at the expense 
of uric acid (Kolisch); formation of uric acid in kidneys from urea and 
glycocin (LufI); inherent morbid metabolism and neurotrophic disturb- 
ance (Duckworth). The elements that seem to be most probably pres- 
ent are deficient renal elimination and excess of uric acid. 

Sodium urate is deposited in the ligaments, cartilages and synovial 
membranes. These when dry are termed tophi, and excite inflammatory 
processes, resulting in thickening, deformity and loss of motion. Tophi 
may be discharged by ulceration, or in time be absorbed. They have 
been recognized in the cartilages of the ear, larynx, nose, eyelids; in the 
palmar periosteum and tendons, the penis and many other localities. 
The lesions of an acute attack are those of any acute inflammation. 
Deposits occur in the kidneys, followed by areas of necrosis, and granular 
contraction frequently results. Gout is one of the most common causes 
of arteriosclerosis, with cardiac implications. Chronic bronchitis, asthma 
and emphysema are more common sequels than acute respiratory 
affections. 

Etiology: — Heredity exerts a powerful influence. The malady rarely 
begins before middle age, unless heredity is unusually powerful and the 
habits strongly favor the development of the malady. After the 50th 
year primary attacks are rare. Men most frequently suffer the arthritic 
form, women from irregular gout. Over-eating, of animal foods, with 
a sedentary life, is the potent cause. The use of alcohol, especially of 
malt liquors, sweet and fermented wines, hence the habits and customs 
of the wealthy, strongly dispose to gout. Workers in lead are especially 
affected. Finally, traumatism may occasion the acute outbreak. 

Symptoms: — Patients complain of digestive disturbances, wandering 
pains, muscular cramps, asthma, insomnia or disturbed sleep, depression, 
but more frequently of general unrest and irritability cf temper. Some- 
times the warning comes in a sense of well being. The excretion of uric 
and phosphoric acids is diminished. 

The attack occurs generally during the early morning, the patient 
awakening with pain in the metatarsophalangeal joint of one great toe, 
which increases till unbearable, feeling as if crushed in a vice — the pain 
of confined fluid. The part swells, with redness, tenderness, heat and 



238 GOUT 

loss of motion. The surrounding skin pits and becomes shiny. The 
temperature rises to 102 — 103, and the patient shows excessive irritability. 
In one or two hours the symptoms subside, free sweating occurs, and 
great is the relief. The evidences of inflammation do not vanish, and 
on the following night the story is repeated, with emphasis. This goes 
on for a few days or a week, when the attacks moderate, the skin peels 
off, and free movement becomes possible. Usually there follows a delight- 
ful sense of well-being, mental and bodily, and the patient will tell the 
doctor that all the " meanness" has been cleared away from his system. 

The recurrence of attacks depends largely on the patient's habits; 
usually they tend to recur more frequently, though the attacks may be 
less severe. Other joints are involved. Suppuration does not follow. 

Sometimes the local symptoms suddenly disappear and simultaneously 
evidences of disease of some internal organ appear, acute pains in the 
stomach, heart, brain, or elsewhere, with symptoms of acute inflamma- 
tion there. This is known as retrocedent gout. Such attacks may prove 
fatal. 

As the malady becomes fixed the attacks grow milder, longer, until 
they become continuous. Other joints are affected, the hip and shoulder 
excepted. The deposits interfere with motion; the skin over them may 
ulcerate, so that the patient may be able to write on a blackboard with 
the chalky deposits. Much distortion results. 

Among associated conditions are catarrhal gastritis, arteriosclerosis, 
cirrhotic kidney, cardiac scleroses, etc. The course is diversified by 
acute attacks and intercurrent complications, or by uremia. 

All cases manifested elsewhere but in a joint are termed irregular 
gout. These are seen in women and men who inherit gout,' but not in 
the most marked degree. It less frequently occurs in men who have 
had the regular form and have mended their habits, but not quite enough. 
We may then have pains in the joints and muscles, worse in the early 
morning, with arthritic inflammation of subacute grade; digestive diffi- 
culties, tonsilitis, parotitis, pharyngitis, pericarditis; arteriosclerosis and 
cirrhotic nephritis; headaches, neuralgias, paresthesise, palmar and plantar 
pains, hot itching eyeballs, atheromatous apoplexy, basilar meningitis, 
neuritis, irritability cf temper and even mental aberrations; scanty red 
urine, uric showers, gravel, glycosuria, oxaluria, cystitis, hematuria, 
urethritis, prostatitis, orchitis; bronchitis, asthma, emphysema; eczemas 
and other cutaneous irritations; ocular inflammations, hemorrhagic 
retinitis, glaucoma; affections of the external ear. 

Diagnosis: — Acute gout first attacks the small joints, especially the 
great toe; does not wander from joint to joint; the tenderness on trans- 



GOUT 239 

verse pressure is greatest over the condyles; the history points to gout; 
tophi may always be found; the fever is slight; cirrhotic nephritis with 
high vascular tension develops; the joints in time are distorted; the blood 
serum may show the uric acid test. Acute rheumatism affects the large 
joints first; wanders; tenderness is greatest in the tendons over affected 
joints and is great in the skin; the history differs; fever is higher; the 
kidneys are not affected, nor does arteriosclerosis raise the tension. 
Arthritis deformans is not hereditary to gout, affects women and the poor, 
is excited by nervous causes, commences in the fingers and develops 
symmetrically, is more regularly progressive, shows marked deformity 
from exostoses and anchylosis, and is not marked by uric acid excess. 

Tredtment: — The greater the hereditary tendency to gout, the more 
decided should be the preventive regimen. Alcohol should be totally 
forbidden, the patient made as nearly vegetarian as possible, active out- 
door exercise required, tea, coffee and tobacco prohibited, and daily 
bathing enjoined. Children thus trained usually escape. Care must be 
taken, however, not to injure the patient's health in the zeal for reform. 
Anemia is to be avoided as well as plethora. Climate and clothing are 
to be suited to the case. 

The diet of gouty individuals should be carefully arranged with refer- 
ence to the patient, and hence great latitude is necessary. But it is always 
wise to limit the use of proteids to the needs, and to avoid those meats 
that experience has shown to be most injurious. Articles to be permitted 
are the green vegetables, farinacea except oatmeal, fruits except bananas, 
tomatoes and strawberries; oysters, milk, eggs and fats; most fish, but not 
salmon, herrings, sardines, mackerel, halibut, codfish or flounder; the 
white meat of chicken; stale bread. Articles to be avoided are alcohol, 
tea, coffee, hot bread, pies and cakes, sweet puddings, cheese, dried beans 
or peas, dried or smoked meats, pork and veal, goose or duck, and all 
high seasoned dishes. If more meat must be allowed it should be beef 
or mutton. Patients who are so accustomed to rich food that they lan- 
guish if deprived of it, or become rebellious, may be satisfied by giving 
them fried egg-plant, tomatoes, cucumbers or apples. In general all 
vegetables containing volatile oils should be excluded, such as water- 
cresses and the whole onion tribe. 

The free use of alkaline mineral waters is nearly always commendable. 
They are best taken between meals, on rising and on going to bed. 

Colchicum has long been known as the most effective agent to promptly 
relieve the acute attack. Unfortunately the pharmacopoeias listed two 
fluid extracts, two tinctures and two wines, each with a different dose, 
and all so variable that they were practically useless. The pharma- 



2 4 o LITHEMIA 

copeia now, however, has listed colchicine, the active principle upon 
which the virtue of all these preparations depended; and the rapidly 
increasing use made of this alkaloid testifies to its value. Unfortunately 
colchicine is extraordinarily slow in its action, though it does not require 
fourteen hours like the older preparations; It is necessary to administer 
colchicine until unmistakable evidence of its action is presented in the 
shape of nausea or diarrhea. The dose of gr. 1-134 may be given dis- 
solved in hot water every three hours until the above symptoms are mani- 
fested. Coincidently with these effects the gouty pain and inflammation 
subside. It is well to give the patient at the same time an abundant 
supply of alkaline beverages, the salts of lithia usually being preferred. 
The application of hot flannels or a solution of iodoform in ether as a 
liniment affords notable relief from the acute suffering. 

During the intervals colchicine should be continued, a single dose 
being given at bedtime sufficient to act slightly upon the bowels in the 
morning. During the acute attack the bowels should be completely 
emptied by saline laxatives, repeated daily; and during the intermissions 
the patient should take a moderate dose of podophyllotoxin at bedtime 
with a saline next morning. 

While colchicine is less markedly beneficial in chronic and irregular 
gout, it is nevertheless our best remedy. Calcalith (calcium carbonate) 
has proved of great benefit when given well diluted with water, neutraliz- 
ing uric acid and carrying it out of the body. Whenever vascular tension 
is raised, as it so frequently is in chronic gout, veratrine should be added 
to the other treatment in doses sufficient to subdue tension to the normal 
standard. This is also an excellent alternant for colchicine and the best 
substitute for the latter when for any reason it may be unadvisable. Anemic 
patients require the usual treatment of that affection, while in all forms 
of the malady scrupulous care must be given to keeping the bowels clear 
and aseptic, the elimination fully up to the standard. The greater the 
failure of renal elimination, the more imperative it is that the unavoidable 
work of these organs should not be unnecessarily increased by improper 
diet. 

LITHEMIA 

In lithemics there is an excess of uric acid which increases more rapidly 
than it is eliminated. The causes are those of gout, namely, a sedentary 
life and the use of foods, especially proteids and sugar, to a greater extent 
than the needs of the body justify. Lithemia in America seems to replace 
gout in England. The different manifestations resulting from the opera- 
tion of identical causes may in part be explained by the difference in 



LITHEM1A 241 

climate; but as the effects of inherited wealth are transmitted to succeed- 
ing generations in America, we find typical gout growing more frequent. 

Symptoms: — These are in many cases identical with those already 
described under the head of irregular gout. We find in lithemia, however, 
a special irritability of the genitourinary mucous membrane, in which 
slight causes induce inflammation which proves obstinate and not readily 
amenable to treatment. Dyspepsia in some form is almost always 
present, generally with acidity, heartburn, pyrosis and flatulence. The 
starches are not well digested, and indulgence in sugar is especially likely 
to cause acute indigestion. The breath becomes offensive; the bowels 
are disturbed, the stools offensive and unhealthy and hemorrhoids are 
frequent. Palpitation and other neurotic heart phenomena are common. 
The skin is dry and irritable; itching is exceedingly common; the nails 
become brittle, the teeth decay early, and the hair falls prematurely. 
Toxemic headaches are very common indeed. Vascular tension is gener- 
ally increased. An enormously long list of symptoms has been attrib- 
uted to uric acid. It is now known, however, that uric acid is not the 
materies morbi and that most of these difficulties can be attributed to 
absorption of the products of fetal decomposition. Nevertheless, it is 
convenient to retain the name since the profession and the public have 
been educated up to quick recognition of the conditions incident to a lazy, 
indulgent life, and the means of remedying them. 

Treatment: — The treatment should begin by instructing the patient 
in the art of eating: He should be taught what to eat, when to eat and 
how to eat; the diet should be regulated by the physiologic needs instead 
of by the appetite. Exercise should be enjoined; at first in strict modera- 
tion, carefully avoiding muscular strain and over-fatigue. As the patient's 
muscles become trained and developed, their work should be increased 
and varied, the results being carefully noted until the balance between 
that particular patient's needs of daily exercise as well as of daily food 
has been determined. The diet is practically the same as that recom- 
mended for gout; the free use of alkaline waters between meals is to be 
commended but quite frequently it will be found necessary to administer 
hydrochloric acid with the meals. The bowels must be kept clear and 
aseptic; a moderate morning dose of saline in a half pint of hot or cold 
water is advisable. Calcium carbonate is. perhaps the best diuretic and 
uric acid solvent in existence. Sometimes the liver is sluggish, when 
bile is indicated; and sodium sulphocarbolate should be given whenever 
the stools are offensive, in doses of five grains after meals, increased to 
whatever quantity may be needed to render the stools odorless. As an 
almost invariable rule the digestion is so weak that artificial digestanU 



242 RICKETS 

will be required, while at the same time the use of cold drinks at meals 
must be absolutely forbidden. It is much easier to lay down the correct 
regimen for each patient than it is to induce them to adhere to it as long 
as may be necessary. As a rule it is best to use radical measures and 
urge upon the patient the wisdom of changing his occupation to whatever 
may seem ideally suitable to his particular case. 

RICKETS 

This is a disease of early childhood, affecting the bones and cartilages 
and causing deformity. Nutrition is retarded and the growth of parts 
of the skeleton checked. The ends of long bones soften, the bone already 
deposited being absorbed. The ossifying layers become soft and thickened, 
the periosteum loose; cartilage cells proliferate, and the fontenelles remain 
open or even enlarge, forming areas known as craniotabes. The per- 
centage of lime in such bones is quite small. The liver and spleen enlarge, 
and sometimes the mesenteric glands. 

Etiology: — It is said that over 75 per cent of children born in Vienna 
show evidences of rickets. The erudite professors of the medical schools 
of that city, however, are usually drawn from other localities. Many 
such children are stillborn; those that survive childhood being dwarfs. 
Heredity has some influence but not as a rule directly, the mother being 
rather the victim of ill-health, over-work and under-nutrition, lack of 
fresh air and sunlight, perhaps syphilitic, and her health further deter- 
iorated by nursing. Phthisis in either parent may aid the causation of 
rickets. It is a disease of cities rather than of the country; of Europe 
rather than America. In this country the majority of cases is furnished 
by the negro. It occurs among the poor, living in densely crowded, 
badly ventilated, dark tenements; more frequently among children brought 
up by hand, and especially if the milk is sterilized. A diet poor in pro- 
teids and fat is apt to develop rickets. The disease generally appears 
between the ages of six months and two years. 

Symptoms: — The onset is usually unnoticed. We have first symp- 
toms of disordered stomach, the food disagreeing with the child; its sleep 
is disturbed; the child is restless and irritable, has slight fever, perspires 
about the head especially when asleep, and tries to throw off the bed- 
clothes. Tenderness occurs, with languor, so that the child dislikes to 
move or to be handled. The mother complains that the child, which 
had sat up strongly, now hangs its head as if unable to sustain its weight; 
it cries when compelled to sit up. A diarrhea commences then, not offen- 
sive nor very prominent but remarkable in that it resists the ordinary 



RICKETS 243 

domestic remedies and grows worse on opiates. It becomes lienteric 
also, the food passing through undigested. The child loses flesh and 
becomes anemic while the white cells usually increase in number. 

The check of development of the face makes the cranium appear 
enlarged. The sutures and fontanelles remain open, sometimes for 
years. Craniotabes occurs in infants under a year. It is caused by 
pressure from within and without, and is seen in bones on which the 
weight rests, such as the occiput, which is thin and soft. Palpate lightly, 
away from sutures. Crainosclerosis, abnormal hardness, sometimes 
occurs. The head is square, flat on top, bony thickening sometimes 
making the parietal and frontal bones prominent. The blue veins show 
plainly, and the hair is scanty and rubbed off the occiput. A systolic 
murmur may be detected over the anterior fontanelle. The teeth eruption 
is delayed, and they are ill-formed. The costal ends of the ribs swell 
forming the rachitic rosary, which may persist till the fifth year. The 
chest is flattened at the sides, pushing the sternum forward — pigeon breast. 
Harrison's groove is a furrow passing from the anterior end of the ninth 
or tenth rib toward the axilla, more evident during inspiration. At the 
junction of the shaft and epiphysis of the radium a swelling occurs, and 
both bones may be twisted out if the child crawls. Both ends of the 
clavicle club, and the scapulas may enlarge. If the spine is affected 
deformity may result. 

The rickety pelvis offers the most serious of obstetric problems, the 
diameters being so diminished as to render cesarean sections necessary. 
The bones of the legs give way to the child's weight, and bow or angu- 
late. The joints are large and the bones short and thick, so that the 
patient remains of low stature. 

Children affected with rickets are specially prone to spasmodic croup, 
tetany, convulsions, and dyspeptic disorders. The abdomen projects, 
the lungs are ill-developed and the bones break easily with green-stick 
fractures. The writer has noted among such children a tendency to 
Raynaud's disease, Addison's disease, and to alcoholism — possibly coinci- 
dences. But any devolutional processes may be expected in these unfor- 
tunates, especially an unstable nervous equilibrium. One such family 
displayed among the numerous children tetany, Raynaud's disease, genius 
and eccentricity rather closely allied to insanity, extraordinary physical 
strength, a tendency to vasomotor perturbations, and a curious case in 
which the typical symptoms of Addison's disease were spread over a 
period of ten years, ending in pulmonary tuberculosis. 

Diagnosis: — The typical diarrhea, lienteric, the difficulty in support- 
ing the head although the child had previously sat up strongly, the sweat- 



244 RICKETS 

ing about the head during sleep, restlessness, delayed closure of the fon- 
tenelles and eruption of teeth, are significant. In later life the deformities 
are characteristic. It is important that the diagnosis be made early that 
the malady may be promptly checked. 

The prognosis depends mainly on the doctor — if he recognizes the 
disease soon and institutes proper treatment it is easily managed. 

Treatment: — This should begin with the pregnant mother, who should 
be placed in suitable hygienic conditions, with abundance of fresh air 
and nutritious food, enlivening social surroundings, and not too much work. 
She should have an abundance of lime salts in her food — the writer spe- 
cially advises oatmeal scones, not porridge. Cod-liver oil, iron, man- 
ganese, calcium lactophosphate, and particularly attention to the bowels 
and kidneys, are useful in appropriate cases. 

The child must have fresh air, sunlight, proper food properly digested, 
a plentiful supply of lime, and diastase to digest the starches. The lac- 
tophosphate of lime is soluble in water, and probably is more readily 
disposed of by the digestive and assimilative organs than any other lime 
preparation. Five to ten grains a day should be given, in the food. The 
diet must be carefully arranged with reference to the child's age and 
digestive capacity. Cod-liver oil is a useful addition. The diarrhea 
is often controlled better by diastase than by any other remedy, though 
copper arsenite, gr. i-iooo to 1-5000 every two hours, is quite effective 
in lientery. The best intestinal antiseptic here is calcium sulphocar- 
bolate, which may be given up to full toleration with benefit. A child 
in its first year will take a grain every hour with ease. Phosphorus has 
been urged by many, and seems really effective. Zinc phosphide may 
be employed in doses proportioned to weight, -the dose for an adult weigh- 
ing 150 pounds being gr. 1-6 four times a day It must not be continued 
more than one week out of each month. During the remainder of the month 
the child should take neuro-lecithin in full doses. The ordinary tonics 
given indiscriminately are worse than useless. None should be given 
unless there is a clear indication for that particular agent, and watchful 
care is necessary as even a needed tonic may pass through the bowels 
unutilized. Hot salt baths are most useful, followed by rubbing the 
entire body with hot cod-liver oil — the real thing, as odorous as it is pos- 
sible to obtain. Fresh fruit juices are useful, and meat juices such as 
red dish gravy. Predigested milk is generally better than the plain, unless 
it can be given warm from the cow. The stools must be closely scrutin- 
ized as the food is always apt to pass undigested. 

The child should not be permitted to sit up, or crawl, or walk, as 
long as there is danger of the soft bones giving way and bending. The 



SCURVY 245 

position should be changed often to prevent the occiput flattening or being 
dislocated under the edges of the parietals. 

Of the above treatment the hygienic part is essential, the rest adjuvant. 

SCURVY 

Scurvy is a malady that is apt to be overlooked because we generally 
think of it as one that used to affect sailors before ships were required 
to carry limejuice. In fact, scurvy is likely to affect our own patients, 
even in the wealthier classes, under proper conditions; and the writer 
believes that some of the debility of convalescence from continued fevers, 
too rigidly dieted, is really scorbutic. Under similar conditions a member 
of the faculty of one of the most prominent medical universities in this 
country was found to be suffering with scurvy. 

While the causes of scurvy are well known, the pathogenesis is obscure 
and will be until we know more of the role played in the organism by 
the vegetable acids and other elements of our food. The blood is thin, 
dark, deficient in hemoglobin and red cells, prone to slip out of the vessels, 
especially under the periosteum of the femur. 

Etiology: — The occasional occurrence of epidemics indicates the 
infectious nature of the malady. Testi and Beri claim to have isolated 
a diplococcus which produced in animals symptoms resembling those of 
human scurvy. The chief factor in the development of this disease is 
the absence of fresh vegetables from the diet for prolonged periods. The 
organic potassium salts, the hydrochloric acid and the total acidity, are 
thereby reduced. This may open the way to the invasion of microor- 
ganisms against which the body is ordinarily protected by the food ele- 
ments derived from fresh vegetables. All debilitating influences, bodily 
and mental, favor the development of scurvy. 

Symptoms: — The onset is slow. The loose tissue about the eyes 
looks swollen and bluish, the face pale and apathetic, and 'the patient 
finds himself growing weak and disinclined to physical or mental exertion. 
The bones, joints or muscles ache and dyspnea arises. Wasting follows. 
The gums become soft, spongy and swollen, ulcerate, bleed readily; the 
teeth loosen and fall; the breath is offensive even if there is no necrosis 
of teeth or bone; the tongue is pale, flabby and swollen; the appetite is 
languid, though digestion is fair, but easily disordered by too much food. 
Constipation is more common than diarrhea. Dysentery occurs in hot 
seasons and latitudes. The skin is dry, muddy or sallow sometimes 
chlorotic. Hemorrhages occur under the skin and mucosa; around hair 
follicles, and under the periosteum. Brawny induration appears in the 



246 SCURVY 

calves and thighs. Epistaxis and other mucous hemorrhages are fre- 
quent, and blood may be effused into serous cavities. Tenderness develops 
in many places. The heart becomes weak, palpitates, affords anemic 
murmurs; the temperature is subnormal unless some inflammatory malady 
causes fever. The patient is depressed, apathetic, sleeps poorly, and 
may develop delirium, and day or night blindness. The urine is red, 
heavy, albuminous, rich in phosphates, the other solids diminished. 
Nephritis may follow. The bones may necrose, old scars break down 
and wounds reopen. Bedsores form readily. The tissues are particu- 
larly prone to fall into abscess or necrosis from slight pressure or 
traumatisms. 

Diagnosis: — This rests on the history of deprivation of fresh vege- 
tables, the affection of the gums, apathy, debility mental as well as physical, 
hemorrhagic tendency, and prompt improvement following reform of diet. 

The prognosis is good enough if the remedy is accessible and the 
disease has not occasioned destruction of tissue. Pulmonary and renal 
lesions may be grave. 

Treatment: — The tin can has extinguished scurvy in modern armies 
and navies. Any fresh plant food will prevent or cure the disease. Sailors 
in the Antarctic gather any green plant they may find on the islands and 
prepare it as a tea or as spinach. Even fresh meats have their influence, 
and the raw blood of a seabird has saved life. Raw eggs and milk have 
been found beneficial. Even raw fish have stayed the progress of scurvy. 
While all fruits and vegetables are useful, it seems that there is more value 
in these when taken raw and unpreserved. It is useless to specify lemon 
or orange juice as any other answers as well. It is what is to be had 
that cures in emergencies. During sieges men have kept scurvy off by 
drinking teas made from grass or any non-poisonous weeds. . 

A little hydrochloric acid with meals is useful, and seems to restrain 
the tendency to disintegration of the tissues as well as securing better 
digestion. Constipation is relieved by enemas or salines; diarrhea by 
antiseptics; the mouth may be treated by lotions of any astringent and 
any potash salt, or any antiseptic in mild solution. Hemorrhages are 
more amenable to tannic acid than to mineral astringents. Tannic acid 
internally has a little effect in delaying the necrosis of tissues. The vege- 
table acids, citric, tartaric, malic, acetic, and their potash salts, have less 
effect for good than the vegetables containing them. 

We do not know quite all there is as to the physiology of digestion and 
the uses our bodies make of various food elements. 



INFANTILE SCURVY 247 

INFANTILE SCURVY 

While this malady generally coexists with rickets it sometimes occurs 
alone. Hemorrhages occur beneath the periosteum, forming tender 
swellings, the muscles are infiltrated, and the lesions of rickets appear. 
The general view is that while the disease resembles rickets the exciting 
cause is different. 

Infantile scurvy occurs in hand-fed children, sometimes following 
the use of sterilized milk, or ''infant foods". It commences between 7 and 
14 months, and in children of the wealthy, when the artificial food is wid- 
est from the mother's milk. 

The skin is muddy, the infant wastes, becomes irritable and cries 
when moved, especially when the legs are handled. Effusion under the 
femoral periosteum gives the thigh a cylindric shape. The legs flex, later 
becoming straight and everted. Other bones are affected but less promi- 
nently. The gums swell, petechias appear on the skin, especially about 
the eyes, and pufiiness on an eyebrow- with slight staining of the upper lid 
has been described, the other eye being similarly affected later. Mucous 
hemorrhages also appear. 

Diagnosis: — From ordinary rickets this malady differs in the promi- 
nence of the thigh affection, excessive tenderness, general swelling of the 
legs, tense shiny skin seldom pitting, without local heat, and liability to 
fracture near the epiphyses; the gums affected only about erupted teeth. 

The prognosis is good. 

The treatment is by the establishment of proper diet, including well 
selected milk and the fruit juices; fresh air, sun baths, hot salt baths 
followed by rubs with hot cod-liver oil, aids to digestion, especially an 
efficient diastase in generous quantities, and the use of splints to prevent 
deformity if required. 

PURPURA 

Purpura may be secondary to scurvy, acute infections such as cereb- 
rospinal meningitis, smallpox, measles, septicemia, ulcerative endocar- 
ditis, hemophilia, nephritis, leukemia, pernicious anemia, jaundice, 
Hodgkin's disease, tuberculosis, malignant sarcoma; locomotor ataxia, 
myelitis, hysteria; traumatisms, straining, whooping-cough, convulsions; 
quinine, copaiba, belladonna, ergot, mercury, iodides; or serpent venoms. 
Primary cases are ranked as p. simplex, p. arthritica including peliosis 
rheumatica and Henoch's, and p. hemorrhagica. 

Purpura simplex: — The cause is not known, but the disease is most 
frequent about puberty, following acute infections. Cutaneous hemor- 



248 PURPURA 

rhages appear as petechias, vibices or ecchymoses — the first minute dots 
of blood in the hair follicles, the second in streaks, the third larger ex- 
travasations in patches. They range from deep red to bluish, fading 
through brown and yellow. They appear in crops, and often on the legs. 
Bloody bullae or blisters may appear. Gangrene has been known to 
follow. 

Pelhsis Rheumatka: — Schoenlein's Disease: — It may be rheumatic 
but cardiac disease is not often present. It is most frequent in men be- 
tween 20 and 30. Prodromata are angina, slight joint pains, headache, 
anorexia. The temperature runs from 100 to 102; especially with in- 
flammation of numerous joints. Purpura is sometimes attended by 
urticaria, exudative erythema and subcutaneous edema. The purpura 
occurs mostly over the affected joints and the legs. Intense itching at- 
tends the urticaria. Epistaxis is more frequent than other mucous hem- 
orrhages. Edema may be very prominent. There may be albumin- 
uria, or slight fever. Convalescence is long, relapses are common. The 
diagnosis embraces the three cardinal features, polyarthritis, purpura and 
edema. Purpura with urticaria is significant. The diagnosis is good 
but complications may be serious. 

Henoch's Purpura: — This occurs in children, with inflamed joints, 
purpura and erythema multiforme, vomiting, diarrhea and abdominal 
pain, local cutaneous edema, mucous and sometimes renal hemorrhages. 
The diagnosis is difficult if the purpura is illy defined. Prognosis good 
if without complications 

A case was reported in which purpura could be developed like urti- 
caria by drawing a pencil over the skin. 

Purpura Hemorrhagica— Werlhof's Disease:— This is most common 

in young women, with malnutrition, especially if rheumatic or malarial. 
It is now regarded as infectious. There may be a few days of prodromes, 
headache, malaise, anorexia and depression; then a rather abrupt onset, 
fever, and ecchymoses in the skin, rapidly multipying. Slight mucous 
hemorrhages also occur. Epistaxis is most common but bleeding may 
occur and recur from all the mucosa. Prostration is marked, with aching 
in the legs, loins, abdomen and in the chest preceding a hemorrhage. The 
temperature rarely rises above 103; the pulse is rapid, full and regular 
except in grave forms; the mind is clear, the face anxious. Hematuria 
and nephritis sometimes ensue. Anemia follows the hemorrhages. The 
lymphocytes and small mononuclears multiply. The attack lasts a week 
or more, severe cases going longer. A malignant form is quickly fatal. 
Diagnosis: — Scurvy is distinguished by its history, the spongy gums, 
loosening teeth and brawny indurations. Purpuric petechia? do not 



HEMOPHILIA 249 

occur in the hair follicles, and mucous bleeding is far more serious than 
in scurvy. Hemorrhagic eruptive fevers are to be Separated by the his- 
tory of exposure, and by the characteristic prodromes and invasion. 

The prognosis of purpura is grave, from complications, repeated bleed- 
ings, or from the system being overwhelmed in malignant forms. 

Tredtment: — Secondary forms require the treatment of the primary 
malady. Anders advises arsenic pushed to toleration. Legroux lauds 
perchloride of iron, in doses of half to one dram daily, with oxygen in- 
halations to promote hematosis. In rheumatic forms the salicylates 
should be given. In all cases the patient should be confined to bed, 
with plentiful nourishment, easily digested or predigested, and fresh air 
ensured. The ordinary hemostatics are always tried, and in the writer's 
experience are worthless, iron notably injurious. Ergot does no good 
but if in large doses is harmful. Calcium chloride is probably effective. 
Locally a solution of cocaine, 2 per cent, has promptly and effectually 
restrained the bleeding. The bowels should be kept free by salines, and 
disinfected by calcium sulphocarbolate, about 40 grains per diem. Rhus 
aromatica has been found effective as a hemostatic. Turpentine has 
been recommended, and possibly the oils of erigeron and eucalyptus, 
which have proved effective in renal hematuria, may succeed here. Dis- 
tinct benefit followed in one case when hamamelin was administered 
with free hand. But every physician will try the list of hemostatics in 
succession, until he finds for himself that they are worthless and that 
purpura is not simply a hemorrhage. 

HEMOPHILIA 

The "bleeder's disease" is transmitted by the females of affected 
families, themselves unaffected, to their male descendants only. The 
muscular coat of the arteries is atrophied or absent, the vasomotor equilib- 
rium is unstable, and hemorrhages occur spontaneously or on slight cause, 
exceedingly difficult to restrain. Rarely women suffer. The men of 
bleeder families are large and vigorous, with delicate complexions, and 
the malady manifests itself in the second year or not until puberty. 

There may be a slight break of the skin or mucosa, tooth extracted, 
or a blow, bleeding sets in and goes far beyond the reasonable expecta- 
tion. Or the hemorrhage may be spontaneous, epistaxis being very com- 
mon. The hemorrhage may be from the skin, mucosa, or as ecchymoses. 
It may be free enough to soon destroy life but generally is in the form of 
venous oozing. Extravasations follow slight bruises or form where pres- 
sure has been exerted. Anemia ensues in proportion to the loss of blood. 



250 HEMORRHAGES OF NEWBORN INFANTS 

The blood if examined in ordinary times or before hemorrhages does not 
show anything abnormal except perhaps an excess of leucocytes, not 
marked. Bleeding may occur into the large joints, such as the knee. 
Arthritic inflammations sometimes occur, especially in damp, " rheumatic " 
weather, and these may precede an outbreak of hemorrhage. The joints 
may be permanently injured. 

The diagnosis can not be made from persistent oozing of blood unless 
the heredity is established. The presence of joint disorders, and repeti- 
tions of the bleeding from insufficient cause, aid the detection of this 
malady. Edema and urticaria distinguish peliosis rheumatica. If the 
disease develops early, many die in childhood. If it does not appear till 
puberty the danger is much less. First hemorrhages are rarely fatal. 
Menstruation is not dangerous, and while most physicians dread bleeders 
in confinement, Kolster's records of 130 cases did not show an extra- 
ordinary fatality from bleeding, there being only three deaths of mothers 
and 16 abortions. 

When a man is known to be of a bleeder family all surgical operations 
should be tabooed, even the bite of a leech having proved the source of 
dangerous hemorrhage. The gums must not be lanced, or the child 
circumcised, and appendicitis must be permitted to recover without opera- 
tion. Women of such families should be forbidden marriage and maternity. 

The patient during an attack should be kept at rest and every effort 
made to control the bleeding by pressure. Mineral astringents are worth- 
less, but good results have been obtained from the local application of 
turpentine. Cocaine solutions locally have quickly checked the bleeding, 
and suprarenal extracts succeed but require frequent repetition. Calcium 
chloride has accomplished probably more than any other remedy intern- 
ally, and calcium is probably the active agent in gelatin. Hydrastinine 
is of unquestionable value though slow to act. Iron, ergot and all mineral 
astringents do harm. Tannic acid used to plug a tooth cavity succeeded 
in one case. Great care must be exercised during convalescence if iron 
is administered to restore the blood crasis, as it is apt to cause renewed 
hemorrhage. Calcium lactophosphate is advisable in doses of gr. 5 
daily, divided, for several months, 

HEMORRHAGES OF NEWBORN INFANTS 

Epidemic Hemoglobinuria— VI inckeVs Disease:— An infection occur- 
ring in hospitals in children under 10 days of age. The infant refuses to 
nurse, is jaundiced, and has gastroenteric catarrh. The urine is scanty, 
dark, contains albumin, casts and methemoglobin. Mucous and parenchy- 



HEMORRHAGES OF NEWBORN INFANTS 251 

matous hemorrhages occur, with slight fever, convulsions and rapid emacia- 
tion. Death usually results. The disease may be produced by growth 
of the colon bacillus in the infant's mouth. In some cases only diplococci 
were found. The disease may be caused by any of several microorgan- 
isms. 

Buhl's Disease: — This is another infectious malady of newborn 
infants, resembling the preceding but characterized by cyanosis, jaundice, 
copious visceral hemorrhages, and acute fatty degeneration of several 
organs. 

Syphilis: — This is occasionally the cause of hemorrhages soon after 
birth, ecchymoses, mucous bleeding, and especially hemorrhage at the 
navel. It is probably a coincidence that in every case of navel bleeding 
in the writer's practice he has detected syphiFs, and all have been fatal. 
Jaundice develops if the infant lives long enough. 

Morbus Macuhsus Neonatorum:— Gastrointestinal hemorrhage in 
the newborn may be due to trauma at birth, or be independent. Cerebral 
hemorrhages are frequent. Gaertner attributes the disease to a bacillus 
entering by the naval. Bleeding may occur from the navel, mouth, nose, 
etc. One half the patients die within a week. 

The treatment of all these maladies is uncertain, and should be based 
on general principles. The reader is referred to the chapter on purpura. 



PART III 



DISEASES OF TH E BLOOD AND 
DUCTLESS GLANDS 



ANEMIA 



By this term is designated a state characterized by diminution in the 
quantity of the blood, of its red corpuscles, or of their hemoglobin. There 
may be disease of the blood itself or of the blood-making organs. The 
red cells may be few and their content of hemoglobin high, or vice versa. 
While we infer the existence of anemia by the patient's pallor, languor, 
dyspnea on slight exertion, and palpitation, the blood count is essential 
to a positive diagnosis. 

Simple Anemia: — This is not infrequent as a congenital malady, 
among the city poor, children of weakly degenerates, the victims of bad 
food, unhygienic dwellings and vicious habits. The blood-making func- 
tion is defective. The symptoms are as above given, with headache and 
debility. If the occupation is not specially exacting or laborious pretty 
good general health may be enjoyed for years, until some unusual call 
is made on the hematopoietic apparatus which it is unable to meet. The 
blood examination shows some scarcity of red cells and deficiency in 
hemoglobin. 

The diagnosis is only to be made after the fullest and most searching 
examination has failed to show any appreciable cause for the anemia, 
and even then we know it is secondary but our knowledge is insufficient 
to detect the underlying malady. It may be years before the develop- 
ment of the case has cleared up the mystery. The prognosis is good, as 
the failure to detect causal disease indicates the absence of the more serious 
maladies. 

The treatment consists in arranging the regimen on the lines of hygiene, 
avoiding causes of waste, conserving the energies, regulating the bowels 
and the digestion, and administering numerous minute daily doses of any 
preparation of iron suited to the case, with nuclein to retain the metal in 
the system. Hot salt baths or rubs are useful, and judicious out-door 
exercise, stopping short of fatigue, with sea or mountain air. Residents 



254 ANEMIA 

of altitudes of 9000 feet are all apparently hyperemic, from their high 
color. 

Chlorosis: — This form occurs among girls shortly after the establish- 
ment of the menstrual function. The hemoglobin is deficient. Degenera- 
tive processes are found, with deficient development of the vascular appar- 
atus, and sometimes of the genitals. Blonds are more affected than bru- 
nettes. Males are less frequently -affected. The blood-making organs 
may have been barely sufficient to cope with their duties before the estab- 
lishment of puberty, with no surplus capacity, and the enormous increase 
in the demands then made upon the blood are not compensated by develop- 
ment of this hematopoietic function. Soon the stress begins to tell. There 
is not blood to spare, and amenorrhea is manifested, and if emmen- 
agogs are rashly given the condition is rendered worse. This affection is 
more apt to be developed in children of anemic, tuberculous or other- 
wise unhealthy parents. It is aggravated by bad hygienic regimen, seden- 
tary sunless occupations, or by the unwise drains made by society exac- 
tions. Nervous shock or exhaustion aids in the causation, and absorption 
of fecal toxins has since Clark's time been recognized as a powerful con- 
tributory element. 

The symptoms are the gradually supervening pallor, breathlessness 
on continually slighter exertion, palpitation, languor, debility mental and 
physical, irritability, depression, anorexia, indigestion, general lack of 
tone, vertigo and headache, constipation and flatulence. The fat is not 
affected. The name comes from the blue veins showing through the 
yellow skin, giving a greenish tinge to the complexion. The conjunctivae 
are pearly white or bluish. The nails, lips and tongue show the lack of 
red blood. The skin and extremities are cold, the temperature subnor- 
mal. The pulse is full but compressible. The carotids arid sometimes 
the jugulars pulsate. The heart dilates and soft murmurs may be heard 
over the base. The venous hum, bruit de diable, is heard over the cervical 
veins. Thrombosis may occur. Neuralgias, hysteria, depression, hyper- 
esthesia of the skin of the abdomen, and gastralgia are not uncommon. 
The ankles are edematous by evening. The urine is pale, light and abund- 
ant. Urea excretion is lessened. The blood is pale through the loss 
of hemoglobin, which may fall to 16 per cent. Marked oligochromemia 
with little oligocythemia is significant. The red cells number from four 
to two millions per cubic mm., the whites about 8000. The red cells 
are pale, some macrocytes, many microcytes, poikilocytes in severe forms 
The eosinophiles are decreased. 

Diagnosis: — The greenish face in a girl past 15, with symptoms noted, 
confirmed by blood examination, makes it easj r . Tuberculosis, nephritis 



PERNICIOUS ANEMIA 255 

and the cachexias are to be excluded. The prognosis is good unless there 
is serious congenital maldevelopment of the circulatory apparatus. The 
duration under treatment is about two months. 

Treafment: — Prescribe the hygienic regimen with emphasis. Cut off 
society observances radically. Insure proper food, in proper quantities, 
at proper times, to be eaten properly. Require plenty of sleep, just enough 
exercise, living in the open air, hot salt and later cold baths with rubbing 
until reaction is assured, and resort to the high mountains. A week in 
bed is a good preliminary in severe cases with much vertigo. The diet 
should consist largely of milk, eggs, fish, oysters, and fresh fruit juices. 
All stimulants are injurious. Full doses of papayotin, or of pepsin with 
hydrochloric acid, should be given with the meals to start digestion. 

The remedy is iron. As Niemeyer said, there is scarcely an instance 
in the practice of medicine of equally beneficial results from drugs. The 
form of iron is immaterial so that all be given the patient can take and 
assimilate. More will be utilized if the doses are multiplied rather than 
a few large ones given. Some do well on Blaud's mass, others on the 
soluble citrates or the pyrophosphate. Occasionally we go back to the 
subcarbonate or to Vallet's mass, or to the tincture of the chloride, iron 
by hydrogen, or the malate. But the metal should be given with free 
hand, a dram a day of the mild salts being none too much. Give nuclein 
solution, 30 minims a day, to insure assimilation. Give a saline laxative 
every morning and an occasional colonic flushing, to prevent the iron 
collecting in the bowel as obstructing masses of sulphide. Intestinal 
antiseptics are useful after the preliminary flushing of the bowels, if the 
stools are fetid. The other tonics, arsenic, manganese, quinine, strych- 
nine, quassin, berberine, zinc phosphide, should not be given unless 
clear'y indicated. The practice of commingling all the tonics of the 
materia medica and firing them into the unfortunate patient at one broad- 
side is unworthy modern medicine. The chalybeate waters are useful 
adjuvants. 

PERNICIOUS ANEMIA 

By this term we designate a form of primary anemia which tends to 
increase despite treatment and ends in death. The fat is unaffected, the 
skin pale, tissues and organs anemic except the muscles, and fatty degen- 
eration is general. The heart is large, flabby, pale, easily torn and fatty. 
The epithelium is fatty in the liver, kidneys, stomach, intestines, and 
arterioles. Extravasations of blood are common, and may be seen on 
the retina and serosa, less frequently under the mucous surfaces and in 



256 PERNICIOUS ANEMIA 

the skin. The spleen and liver do not enlarge much but the lymph 
glands are swollen and quite red, their sinuses dilated, with numerous 
phagocytes containing red cells and pigment. Pigment is deposited in 
the liver, spleen, pancreas, kidneys and other organs. In the liver this 
is distributed about the' periphery and middle zone of the lobules. It 
responds to tests for iron. The bone marrow is hypertrophied and deep 
red, with cellular hyperplasia. Sometimes the gastroduodenal mucosa 
is atrophied. The sympathetic ganglia are affected, the posterior columns 
of the cord frequently sclerosed, sometimes the lateral columns, especially 
in the cervical region. The vessels show hyaline degeneration, some- 
times hemorrhages. 

Etiology: — In some cases no adequate cause can be detected — there 
is active hemolysis, defective hemogenesis, or both. Stengel attributes 
this to fecal autotoxemia, Williams to streptococcal infection from car- 
ious teeth. Both are possibly right as to some cases. In other cases no 
sufficient cause has been found during life but the autopsy discloses unsus- 
pected cancer, or parasites such as the anchylostoma duodenalis or both- 
riocephalus latus. Gastric atrophy is probably an effect of the malady 
rather than a cause. Agencies recognizable during life are exhausting 
diarrheas and other discharges, hemorrhages, infections, shocks, preg- 
nancy and parturition with lactation, and the influence of certain cachectic 
toxins whose presence is unsuspected, such as lead, arsenic, malaria and 
the agencies operating through ochlesis and the absence of sunlight and 
fresh air. Pernicious anemias are more frequent among middle-aged 
men, and sometimes occur with remarkable frequency in certain localities. 
This, however, should always be traceable to local conditions, intestinal 
parasites or mineral poisonii 

Symptoms: — The development is imperceptible save in puerperal 
women. Pallor develops, with shortness of breath after slight exertion, 
palpitation, fatigue easily induced, languor, headaches, tinnitus, vertigo, 
anorexia and evidences of a progressively weakening digestion. Nausea, 
vomiting and fainting fits follow, while the skin assumes a semi-trans- 
parent waxy appearance. Prostration increases, the ankles become 
edematous, ecchymoses appear under the epidermis and in the visible 
mucosa, mental exertion is also wearying, and an apathetic state super- 
venes. Low delirium appears in the last stages. Fat may be increased. 
The pulse is rapid, full but compressible; soft blood murmurs are heard 
at the base of the heart and the bruit de diable over the cervical veins, 
which may pulsate visibly. If atrophy of the digestive mucosa occurs 
we have gastrointestinal symptoms prominently. Anemic amaurosis is 
disclosed by ophthalmoscopy. The sclerotics become pearly bluish, the 



PERNICIOUS ANEMIA 257 

liver and spleen too soft to palpate, the bones tender. Respiration quickens, 
dyspnea increases to air-hunger, increased also by serous effusions and 
pulmonary edema. The urine is dark from urobilin, of low specific gravity, 
contains no albumin or glucose, but indican and an increased quantity 
of urea and sometimes of uric acid. There is often some fever but toward 
the last the low metabolism causes a subnormal temperature. When 
the cord is affected there is paralysis of the sphincters and limbs, with 
spasm, and various paresthetic phenomena. The blood may be pale or dark 
and watery, the red cells less than 1,000,000; their hemoglobin increased 
though its total is low. Macrocytes, microcytes, poikilocytes and poly- 
chromatophilia are constantly present. Nucleated red cells are char- 
acteristic of this malady, as normoblasts and megaloblasts. Gigantoblasts 
are numerous. The small lymphocytes are increased as the polynuclear 
cells become fewer. Marked leucopenia is always present (Cabot). 
Myelocytes are generally present in low percentage. The blood plates 
are few. The proportion of proteids to plasma is altered. Ring bodies 
are often found in the red cells. 

Diagnosis: — This is made by the blood examination, and the pro- 
gressive character of the malady, with remissions. First exclude consti- 
pation and autotoxemia; then, examine the stools for the eggs of parasites. 
Gastric atrophy and other maladies may be excluded by expert examina- 
tion by modern methods. Cancer offers difficulty, especially if buried 
in the liver too deeply for manual detection. 

Pernicious Anemia. Gastric or Hepatic Cancer. 

Blood changes Those of secondary anemia 

Red cells fewer than 1,000,000 More than million 

Leocopenia, relative lymphocytosis Leucocytosis 
Earlier in life After middle age 

Few gastric symptoms Prominent gastric symptoms 

Skin lemon yellow Pale muddy, or saffron 

Fat sustained Steady emaciation 

Glands not enlarged Clavicular or inguinals hard 

Stomach signs absent Gastric tumor 

Test meal negative HC1 absent, lactic acid present 

Remissions, rarely cure Progress relentless 

Fever not essential, subnormal late Always some fever 
Dyspnea on raising head Abdominal decubitus 

Skin smooth, or puffy Skin hangs in folds 

Facies apathetic Facies of suffering 

Ankle edema Ascites 

Tender bones Abdominal pains 



258 PERNICIOUS ANEMIA 

The blood examination distinguishes from chlorosis, besides the 
progress, hemorrhages, and the difference in age and sex. 

The prognosis is necessarily bad if the diagnosis is to be sustained. 
Remissions and even intermissions occur. Death ensues in two to twelve 
months. The nucleated red cells become much more numerous shortly 
before death (Billings). Death is due to syncope, cerebral hemorrhage 
or exhaustion. 

TteBtment: — Put the patient in bed, enjoining absolute rest, with 
sufficient massage to maintain nutrition but not enough to exhaust the 
very low vitality. Empty the bowels with mild salines and colonic flushes 
— but empty them. Nothing must be permitted to interfere with the flow 
of nutritive elements from the bowel into the blood, and an empty and 
comparatively aseptic bowel is the first requisite. The diet should then 
be arranged so that a small supply of food, easily digestible or predigested, 
is supplied every four hours. Milk, eggs, fish, oysters, soused meats like 
pigs feet, raw scraped beef, rice, barley water, the breakfast foods, fresh 
fruit juices, turtle and terrapin, and any foods for which the patient dis- 
plays a craving, form the preferable list. The free use of appropriate 
artificial digestives is important — food not fully digested does harm. Hot 
salt baths and rubbing with salted towels are of value in bringing the blood 
to the skin where it meets the oxygen. The blood foods such as bovinine 
and sanguiferrin are of great importance in a malady where assimilation 
is so weak that no unnecessary burden should be laid on it. Raw red 
bone marrow may be eaten on toast with relish, and while the testimony 
concerning it is doubtful there are no chances to be lost in treating this 
disease, and we can not afford to wait for certainty — moreover it does 
no harm. 

Arsenic is praised by Anders, who does not consider the malady curable. 
As there is a marked tendency to fatty degeneration present, arsenic must 
act homeopathically, since it especially causes this process. But as 
arsenic causes in health an affection similar to that displayed by this 
disease, the drug must affect in some manner the unknown sources of 
the malady, and possibly there may be a substitutive action such as we see 
when arsenic has substituted its action for a spontaneous scaly affection 
of the skin. On the same principle phosphorus, which also causes fatty 
degeneration, should be tried faithfully, pushed to toxic effect, in pernic- 
ious anemias. This is best given as zinc phosphide, gr. 1-6 an hour 
before meals, four times a day, for a week; neuro-lecithin being given for 
the balance of each month. Arsenic is best given in the form of copper 
arsenite if there is any gastric or duodenal disturbance; as arsenic iodide 
if any indication for iodine exists or the fat formation is excessive; arsenic 



SECONDARY OR SYMPTOMATIC ANEMIA 259 

bromide if insomnia is prominent and distressing; iron arsenate if well 
borne; strychnine arsenate if the heart and lungs need the stimulus of 
that powerful vital inciter — in a word, the forms of arsenic should be 
suited to the individual needs and faith not pinned on a single form to be 
given for all. But whatever form is given it should be in small doses 
every waking hour, and pushed till the beginning of toxic effect is mani- 
fested in irritation of the eyelids, then slightly diminished until this ceases, 
and kept up steadily. In all cases, the use of nuclein solution will impart 
an efficacy to the arsenic and iron they will not display without this addi- 
tion. Give up to a dram a day of the standard solution — more if the 
repeated blood examinations show that the leucocytes are not unduly 
increased or diminished. 

Saline lavage or hypodermoclysis is useful when the blood becomes 
too scanty to fill the vessels. Intestinal antiseptics are advised by Anders, 
and of these the sulphocarbolates are best, as most surely not destructive 
to the blood-cells as are those he mentions if given freely. 

Nuclein and strychnine arsenate may be given hypodermically in some 
cases with great advantage. Syncope may be promptly checked or 
relieved by glonoin, with strychnine by hypodermic. Nutrition may 
be enhanced by moderately inciting cardiac action, by the milder 
cardiants such as cactin. Streptococcus infection is another reason 
for full nuclein medication, the serums being as yet too problematic 
for dependence. 

Remissions and especially intermissions should encourage us to renewed 
efforts, and be looked upon as verifying our methods. If the malady 
recedes, why may we not make it keep receding ? 

SECONDARY OR SYMPTOMATIC ANEMIA 

Anemia occurs as a symptom or result of so many maladies that it 
requires special discussion, since it is frequently the main object for thera- 
peutics, apart from the causal affection. A vicious circle is often estab- 
lished, the primary malady inducing anemia, and the latter, by supplying 
the morbid tissues an insufficient nutritive material, interfering with the 
recuperative processes. 

The blood examination discloses moderate oligocythemia, the red 
cells numbering about 3,000,000, except in the acute forms following 
profuse hemorrhages. Hemoglobin falls relatively and even more than 
the cells. The adhesion of cells into rouleaux is lessened, and the color 
shows that hemoglobin is distributed to them unequally. They are unequal 
in size also and in staining capacity. Large nucleated red cells — megalo- 



260 SECONDARY OR SYMPTOMATIC ANEMIA 

blasts — appear, with nucleated red cells of ordinary size; and the leu- 
cocytes multiply absolutely and relatively to the number of red cells. 

Etiology: — Large hemorrhages cause acute, repeated small ones 
chronic, anemia. Women bear such losses better than men, infants 
endure them badly. Acute anemia is denoted by sudden blanching of 
the skin, with fainting, dim sight, cold surface and extremities, roaring 
in the ear, sighing, and quick, failing pulse, ending in unconsciousness 
and possibly death. Convulsions may occur. If recovery follows it is 
an unfailing surprise to note how .quickly the lost blood is reproduced, 
even in comparatively weakly people. The water is first restored, then 
the white cells, then the red and finally the hemoglobin. 

Anemia from inanition comes from food insufficient in quantity, 
defective in quality, or from insufficient digestive or assimilative capacity. 
The plasma decreases rather than the cells. 

The losses of albumin in nephritis, of milk in lactation, pus in suppu- 
ration, and in diarrheas and dysenteries, produce marked anemias. Toxic 
forms come from lead, arsenic, mercury, phosphorus and iron. The 
cells are mainly affected. Typhoid and other infective fevers destroy 
many cells, and the parasites of malaria specifically attack the red cor- 
puscles. Tuberculosis and syphilis also destroy many red cells. Fever 
itself is destructive of the red and uses up many white cells if it continues. 
The actual loss is diminished by the activity of the blood-making functions. 

The symptoms have been fully described; they differ only in intensity 
and permanence from those of simple anemias. 

The diagnosis lies in the recognition of the true cause underlying the 
anemia. But practically, when the primary affection is not evident, we 
look for tuberculosis, carcinoma, nephritis, autotoxemia,. intestinal para- 
sites, mineral or cachectic toxemias, wasting discharges or digestive 
difficulties. If none of these can be detected we seek to diagnose 
between pernicious and simple anemias. 

Symptomatic Anemia Pernicious Anemia 

Detectable cause somewhere Primary disease 

Any age Adolescence, early middle life 

Causal history History negative 

Blood changes less marked; stead- Profound distinctive changes 

ily progressive in cancer 
Moderate and relative reduction Marked disproportionate reduction 

Gravity of primary disease Gravity of blood changes 

Symptoms subordinate to primary Symptoms of anemia most prominent 
Responds to treatment Resists treatment 

The prognosis depends on the causal malady. 



LEUKEMIA 261 

The treatment is first that of the cause. Stop the leak; reform the 
habits, then supply materials for repair. The treatment of the anemia 
itself when secondary or symptomatic is that of the essential, with a wider 
range of indications for the choice of the various forms of iron, arsenic, 
and other remedies. Many times the presence of encumbering debris 
will indicate the occasion for iron iodide, the occurrence of headache 
when a habitual anemia is remedied will demand the bromide of iron, or 
of arsenic; the relaxation of digestive organs call for berberine; the weak 
heart, swampy capillary circulation and dropsy require apocynin. There 
is room for the nicest discrimination in the selection of the agents indicated 
and those that will be acceptable to the taste and the assimilation of each 
patient. But in all cases the bowels must be kept clear of residual feces, 
disinfected, and the diet nicely proportioned to the needs and the digestive 
capacity. The more thorough our knowledge of the patient's physiology 
— and psychology often — and the wider the range of our therapeutic 
resources, the greater will be our satisfaction in the practice of our divine 
art. 

LEUKEMIA 

We have in this malady a usually chronic increase in the number of 
the leucocytes with changes in the spleen, lymphatic glands and the marrow. 
Anemia and emaciation coexist, with serous effusions, clots in the heart 
and large veins found post mortem, ecchymoses beneath the pericardium 
and endocardium, and fatty degeneration of the heart muscles. Leucin, 
tyrosin, acetic, formic and lactic acids, with albuminous degenerative 
products, have been detected in the blood, together with Charcot's crystals. 
The alkalinity is decreased. 

The spleen is generally enlarged, sometimes enormously, the capsule 
thickened, adherent in patches where inflamed, its consistence dense 
except early in the case when it may be soft and pulpy. Cut surfaces are 
brown or mottled. The vessels at the hilum are enlarged. The tissue 
is hyperplastic, the cells are granular and fatty, connective , elements 
increased. 

Usually the marrow is affected, rich in lymphoid and blood cells, 
reddish brown and greenish yellow, puslike patches existing in apposition. 
Infarctions may be found. Several forms of leucocytes are present, 
and cells showing karyokinesis. 

In the lymphatic glands we find early and marked hyperplasia, the 
cervical, inguinal, axillary and mesenteric glands being involved. The 
gastrointestinal glands suffer less frequently. The cell-elements are 



262 LEUKEMIA 

increased, and a similar hyperplasia exists in the tonsils, lynph follicles, 
tongue, mouth, pharynx, thymus and the intestinal glands. The liver 
may be greatly enlarged, infiltrated, engorged with leucocytes and lym- 
phoid cells undergoing nuclear division; the affection being disseminated 
or confined to areas. Similar changes occur in the kidneys, and nodules 
of leukemic tissue may be found in the brain, retina, serosa, lungs, testicles 
and skin. 

Etiology: — The exciting cause is unknown. The phenomena point 
to an as yet undiscovered microorganism as the probable cause. Veh- 
semeyer analyzed 600 cases and concluded the cause was autointoxica- 
tion from toxic albuminoids, from the alimentary canal. Something 
evidently increases the elaboration of leucocytes. Kottnitz attributes it 
to peptone autointoxication. Injury to the spleen has been assigned as 
an excitant, and ulcers of the intestines have frequently preceded the 
attack. Stomatitis may be a means for the entrance of causal microbes. 
Malaria has preceded many cases. Heredity is admitted, bad hygienic 
conditions have an influence, and it develops often during pregnancy 
or at the climacteric. It is however most frequent in middle-aged men, 
but occurs from infancy to old age. 

Symptoms:— The acute form appears in youths, previously healthy. 
The onset is sudden, with prostration, fever and mucous hemorrhages. 
The spleen rapidly enlarges, at times the lymphatic glands swell, and 
severe dyspnea, palpitation and gastrointestinal troubles follow. Anemia 
supervenes and perhaps edema at the ankles. The leucocytes increase 
to 1-30 of the red cells instead of 1-300 to 1-600. As the lymphatic form 
prevails the lymphocytes multiply. Large mononuclear leucocytes and 
myelocytes are numerous, eosinophiles fewer than in chronic forms. 
The case grows worse, hemorrhages occur from the stomach or in the 
retina, brain or skin, and the resemblance to acute infections is close. 
Hemorrhages are less common in the young. 

In chronic forms the onset is slow and insidious, resembling an ordi- 
nary anemia; or the first symptom noticed is an enlarged spleen. Hem- 
orrhages, nausea, vomiting and diarrhea may occur early; or the growing 
pallor may excite apprehension. Priapism has been noted. The anemia 
increases, the ankles become edematous, the pulse quickens and softens, 
fever appears, dyspnea of anemia is increased by serous thoracic effusions, 
and bv the enlarging liver and spleen. Epistaxis recurs more frequently, 
retinal hemorrhages may be detected and leucocytic collections. Mucous 
hemorrhages follow, hemic murmurs may be heard, and local gangrenes 
occur. Intestinal ulcers with dysentery, ascites, jaundice and peritonitis, 
attest the severity of the abdominal malady. Headaches, vertigo and 



LEUKEMIA 263 

syncope attend the cerebral anemia, and death may ensue from apoplectic 
coma with hemiplegia. Deafness may follow small cerebral hemorrhages. 
Priapism may be annoying. Small central hemorrhages may cause local 
paralysis, ecchymoses appear, pruritus adds to the discomfort, and the 
discharge of uric acid increases. 

Splenic enlargement is gradual, painless, not tender, the surface is 
smooth and substance firm. It may be very large. It increases after 
severe hemorrhage or diarrhea. It may cause dyspepsia, constipation, 
jaundice, a splenic souffle; ascites and enlargement of the liver are features. 
The spleen, lymphatic glands and marrow are variously involved, giving 
rise to terms characteristic — spleno-lymphatic, etc. The accessible glands 
may be seen and palpated, soft, resilient, movable. Tenderness over 
the sternum and long bones, slight swelling or deformity, may indicate 
disease of the marrow. The blood is pale, brownish or chocolate colored 
sometimes, the leucocytes increased even to 500,000 per cubic millimeter, 
and may exceed the number of red cells. In the splenomyelogenous 
form the characteristic is the abnormal presence of myelocytes, large 
mononuclear leucocytes with fine neutrophilic granular protoplasm, 
which make up one-fourth of the white cells. The polymorphonuclear leuco- 
cytes are normal or lessened in number, while those showing coarse basophilic 
granules may be as plentiful as the eosinophiles. The lymphocytes are 
relatively less, the bright acid-stained eosinophiles absolutely but not 
always relatively increased. The oligocythemia is not great, the red cells 
numbering about 2,000,000. Hemoglobin may be reduced relatively or 
a little more. Many normoblasts may be found, and cells with large 
pale nuclei, and others with nuclei fragmented, or gigantoblasts. Osier 
found true leukemia developing from pernicious anemia. 

Lymphatic forms are rarer and more rapidly fatal. Lymphocytes 
are increased, all other leucocytes relatively diminished, the former form- 
ing over 90 per cent of all, chiefly small forms. Some nucleated red cells 
are present, some myelocytes, and erythrocytes showing changes in form, 
size and color on staining. Eosinophiles are fewer relatively. Blood 
plates may be abundant. Charcot's crystals appear in the blood on 
standing. Mixed forms of leukemia are common. 

Among complications, are fatal hemorrhages occurring at any time, 
pleurisy, pneumonia, septicemia, renal disease and intestinal attacks. 
Acute tuberculosis reduces the leucocytosis but chronic forms do not 
influence the course of leukemia. 

The diagnosis is made by the examination of the blood, and by that 
alone. Leucocytosis shows a much more moderate increase, mainly of 
polynuclear neutrophiles, with no myelocytes. Pseudoleukemia shows 



264 PSEUDO-LEUKEMIA 

large bunches of lymphatic glands, and simple leukocytosis. Malignant 
and malarial enlargements are excluded by the blood examination. 

Prognosis: — Lymphatic forms progress more rapidly; so do children's 
cases. Most cases are fatal within five years, many in half that time. 
Acute forms kill in two weeks to two months. Advanced cases are hope- 
less. Ominous are profound debility and anemia, severe and obstinate 
hemorrhages, apoplexy, persistent diarrhea and high fever. Intercur- 
rent infections often kill and sometimes exert a beneficial influence. 

Treatment: — Nicholas Senn suggested the first distinctly beneficial 
measure — the application of the x-ray over the sternum, spleen and extrem- 
ities of long bones, for 10 minutes over the viscera, 5 minutes over the 
joints. This is followed by subsidence of the fever, contraction of the 
spleen, increase in red cells and hemoglobin, and a primary diminution 
of the leucocytes, which later reincrease although the patient improves 
in weight and strength. This is most promising and subsequent exper- 
ience may indicate the means of extending and improving these first 
results. 

The hygienic regimen advised under the head of anemia should be 
here put in force in its entirety. A mild dry climate is advisable. Trauma- 
tisms, inflammations, excesses, unhygienic lapses, are to be strictly pre- 
vented. Anders advises arsenic pushed to full tolerance. Iron arsenate, 
quinine arsenate, copper arsenite, strychnine arsenate, arsenic iodide, 
arsenic bromide, each may be employed to meet its special indications, 
alone or in combination. Raw bone marrow may be useful. Saturation 
with arsenic sulphide would be an obvious expedient if this malady is 
really an infection, and if there is no contraindication should be tried. 
In all cases the bowels must be kept free from fecal collection and de- 
composition, and for this we rely on salines by stomach and colonic flushes, 
followed by calcium sulphocarbolate about two scruples per diem. 
Whether the enlarged spleen can be reduced by full doses of berberine, or by 
pushing polymnia uvedalia to toleration, may in the helplessness of 
ordinary therapy be justifiably ascertained by experiment. 

PSEUDO-LEUKEMIA 

Hodgkin's disease presents the anatomic changes of lymphatic leuke- 
mia but the peculiar blood changes are absent. There are two var- 
ieties. In the most common the lymphatic glands are chiefly involved; 
in the other form the spleen is enlarged. Hyperplasia occurs in the lym- 
phatic glands, which enlarge and are matted together in bunches. They 
may be hard or soft. The skin over the masses is usually movable. Sec- 



PSEUDO-LEUKEMIA 265 

tion through a gland shows a smooth white or reddish-gray surface, yel- 
lowish in the firmer glands. Suppuration may occur also. Caseous 
areas or hyaline masses may also be found. The lymph cells are hyper- 
plastic; the older and harder specimens showing connective hyper- 
plasia as well. The- cervical glands are generally involved; the inguinal, 
bronchial and lumbar less frequently than the axillary, mediastinal, scap- 
ular and pectoral. The retroperitoneal glands are more frequently affect- 
ed than the mesenteric. The abdominal vessels and nerves may be com- 
pressed. In four-fifths of the cases the spleen is slightly enlarged, con- 
containing disseminated nodules similar to the glands. Sometimes only 
the spleen is affected. Lymphadenomas also develop in the tonsils, 
tongue, bowels, liver, kidneys, lungs, brain, heart, testicles, retina and 
the skin. Erosion of the vertebrae has opened the spinal canal. The 
bone marrow is often affected also. 

Etiology: — Men are mostly affected, between ten and forty years. 
The predisposing and exciting causes are obscure. It is believed that 
an as yet undiscovered infectious agent is the cause. Tubercle bacilli 
have been found in some of the glands, probably accidental infections. 
It may develop during apparent perfect health. 

Symptoms: — Attention is first attracted to enlargement of a submaxil- 
lary or cervical gland; others become involved and the mass increases 
in size and density. It may be years before another group is affected. 
The general health is not affected at first, but symptoms of anemia grad- 
ually appear with progressive debility, emaciation and derangement of 
digestion. Dropsies follow and hemorrhages occur. A little fever may 
be detected and this may be intermittent, the paroxysms continuing some 
days or weeks. Such cases are acute. As the glands develop pressure 
symptoms arise, varying with the locality. The enlarged glands may 
number hundreds. They are not tender or painful unless nerves are 
compressed. Pressure on the respiratory apparatus may even prove 
fatal. The head and arms may be congested, circulation being main- 
tained through the dilated superficial veins. Edema of one hand and 
arm may result. Pressure on the pneumogastric disturbs the heart, or 
it may be pushed out of place. Pressure on the femoral veins may cause 
dropsy of the legs. Albuminuria is common. Jaundice sometimes occurs 
from pressure. A host of symptoms due to pressure in many parts of the 
body might be described, while pressure on nerve trunks may give rise to 
neuralgia, followed by paralysis in the region of their distribution. Pleuritis 
occasionally occurs, or erythema and sometimes bronzing of the skin. In 
splenic cases the enlargement may be great without lymphatic involve- 
ment. The red cells are somewhat diminished, the white ones increased. 



266 INFANTILE PSEUDO-LEUKEMIC ANEMIA 

Diagnosis: — From tuberculous adenitis the distinction may be diffi- 
cult, but the growth is slower in tuberculosis, extension rare; it is uni- 
lateral, occurs in the young and seems to prefer the submaxilary glands. 
Adhesion and suppuration are more common also. Intermittent fever 
indicates Hodgkin's disease. Microscopic examination of a gland clears 
up the diagnosis. Leukemia is excluded by blood examinations, syph- 
ilis by the history, the occurrence of other syphilitic indications and the 
results of specific treatment. The splenic form is diagnosed by the ab- 
sence of lymphatic involvement. Blood examination distinguishes per- 
nicious anemia with enlarged spleen, cirrhosis of the liver with splenic 
enlargement, malarial spleen and the enlargement which sometimes 
occurs without anemia. 

Prognosis: — The disease is usually fatal, the course ranging from a 
few months to three years. Bad indications are rapid growth of the 
glands or increasing debility, anemia, emaciation, fever, pressure symp- 
toms, hemorrhage or dropsy. The tumors sometimes subside shortly 
before death. General streptococcus infection, intercurrent diseases, 
empyema or nephritis may cause death. 

Treatment: — Surgery has in this disease proved a total failure. The 
x-ray is being tried and some hopeful results have been recorded. The 
treatment recommended for leukemia is to be applied here. Phosphorus 
has been advised and may be given in the form of zinc phosphide, gr. 
1-6 four times a day. Here again saturation with arsenic sulphide 
should be tried, and in splenic cases berberine with quinine arsenate 
given to full toleration. 

INFANTILE PSEUDO-LEUKEMIC ANEMIA 

In this malady the most striking lesion is enlargement of the spleen. 
Its substance is hard and dark red, the tissue uniformly hyperplastic; 
the liver is also enlarged without hyperplasia; the lymphatic glands may 
be slightly enlarged and the marrow has been found to be reddened. . The 
disease affects children under the age of four, being most common from 
six months to one year: Rickety children are most commonly affected, 
syphilis and digestive difficulties also predisposing. 

The attack is insidious, the child growing pale, weak and thin and 
the spleen enlarging. The liver is often enlarged also, the edge being 
sharp. Digestive disturbances occur and the child may die from de- 
bility, peritonitis or pulmonary inflammation. The red cells are reduced 
below three millions and show abnormal forms. Hemoglobin is reduced 
still more, the leucocytes being increased sometimes to one hundred 



SPLENIC ANEMIA 267 

thousand. The disease is distinguished from true leukemia by the 
frequency of recovery, by less hepatic enlargement and by the leucocy- 
tosis. The absence of hemorrhage and lymphadenoma with the history 
of rickets or other cachexia also distinguish it. 

Most cases recover under a good hygienic regimen, attention to the 
bowels and suitable treatment directed to the anemia. 

SPLENIC ANEMIA 

In this disease the spleen is enlarged, with anemia, but no lymphatic 
involvement. The connective tissue is hyperplastic, the gland cells atro- 
phied, the malpighian bodies hyaline. This malady is found in rickety 
persons and others long resident in malarial districts. In the first stage 
extreme anemia is seen, with marked debility and wasting of the muscles 
but not of the fat; in the second stage the spleen enlarges with pain and 
tenderness, profound anemia, extreme debility and hematemesis. Other 
mucous hemorrhages occur and occasionally ecchymoses. Slight fever 
of hectic type is present. In the last period, cirrhosis of the liver, jaundice 
and ascites precede death. The blood shows red cells but slightly de- 
creased with a great reduction in hemoglobin, poikilocytosis and leucope- 
nia. The malady is fairly curable by the treatment advised in grave 
forms of anemia. 

CHLOROMA 

By this title is designated sarcoma in and about the orbit. The color 
is pea-green. Secondary growths occur, also green in color. One case 
was fifteen years of age, another seven. The symptoms are orbital pain 
with protrusion of the ball and deafness followed by severe hemorrhages 
from the conjunctiva and the nose. Swellings appear in the temporal 
and carotid regions. The blood is pale and watery with multinuclear 
leucytosis. Death occurs in a few months. 

ADDISON'S DISEASE 

The disease described by Addison was tuberculosis of the supra- 
renale. Some authors limit the affection to this, while others include 
all structural diseases of these bodies under this term. Tuberculosis in 
the suprarenal bodies is rarely primary but usually associated with the 
same malady in other parts of the body. The capsules are enlarged, 
with hard nodules formed by caseous masses in fibrous envelopes. In 



268 ADDISON'S DISEASE 

advanced cases the capsules are contracted and adherent to surrounding 
structures. The microscopic examination shows a mass of detritus, 
with lymphoid and giant cells. Other diseases found in these 
glands are cirrhosis, carcinoma, sarcoma and chronic inflammation. 
Sometimes the solar plexus and semilunar ganglia are implicated in the 
disease extending from the suprarenals. In other cases there has been 
found enlargement of intestinal follicles and of the spleen, with softening, 
degeneration of heart, liver and kidneys, and persistence of the thymus. 
The bronzing is due to a deposit of pigment in the lower layers of the rete 
malpighii. In some cases no disease of the suprarenals could be detected, 
while in other cases unmistakable disease has been found in these bodies 
when no symptoms of Addison's disease had been presented during life. 

Etiology: — The disease has sometimes followed injury. The con- 
nection with tuberculosis is frequently but not always traceable. Males 
are twice as often affected as females; all ages are liable but it is most 
common between fifteen and forty. 

Symptoms: — The skin gradually darkens to a dusky yellow, yellowish 
brown, olive, deep greenish brown or black. It is most marked on the 
parts of the body exposed to the sun and where pigment is normally depos- 
ited, about the nipples, etc. Bluish spots are also found on the mucous 
membrane of the mouth, lips, conjunctiva and vagina. The skin also 
darkens where pressure is exerted by the clothing. White patches of 
leucoderma are sometimes present but the connection of these 
with Addison's disease is by no means certain. The writer has seen 
leucoderma many times but only once was Addison's disease diagnosed 
in connection with it, and as the lady is still alive after the lapse of twenty 
years and in the enjoyment of good health, the diagnosis was a mistake. 
Many small moles make their appearance, especially where pressure 
has been exerted by the clothing. 

Before or with the bronzing occurs a gradually progressive anemia 
with debility, dyspnea, headache, dizziness, tinnitus, sighing, and bodily 
and mental fatigue induced by progressively slighter exertions. The 
blood examination shows moderate reduction of the red cells and hemo- 
globin, no leucocytosis but often leucopenia; emaciation is not common. 
The heart grows weak, the pulse small and feeble. Palpitation and fainting 
become common, the skin is cool, the extremities cold and soft anemic 
murmurs are heard over the heart. Loss of appetite is an early symptom, 
with general feeble digestion, gastric catarrh with nausea and vomiting 
following in time. Diarrhea occurs later. Neuralgic pain is felt in the 
epigastric, hypochondriac or lumbar regions. The mind is clear, in the 
later stages the patient becoming apathetic, which may end in coma or 



INFLAMMATION OF THE THYROID GLAND 269 

low delirium. The discharge of urine may be very great. It contains 
little urea but indican, urobilin and uromelanin. The symptoms due 
to tuberculosis in some other parts of the body are added. 

Diagnosis: — The peculiar bronzing is characteristic but it may occur 
in a number of other affections, including cancer and tubercle involving 
the peritoneum, diseases of the liver such as diabetic cirrhosis, protracted 
jaundice, chronic congestion and lithemia; pregnancy and uterine disease; 
the irritation caused by dirt, exposure and parasites; tinea versicolor, 
melanotic sarcoma; exopthalmic goiter; the stains remaining after syphi- 
litic eruptions, and argyria, while some persons are brown naturally or 
from exposure. Nevertheless it is exceedingly rare to find in any of these 
affections the peculiar bronzing described by Addison, and especially in 
combination with progressive debility and abdominal pain, the spots on 
the buccal mucosa and the characteristic crops of moles. In the negro 
we must depend on the buccal spots and the general symptoms. 

Prognosis: — Addison's disease is usually described as ending within 
eighteen months but the writer has had two cases presenting this malady 
in typical form with every symptom noted, one of which died at the end 
of ten years, while the other was still alive after that time had elapsed. 
Death is usually due to tuberculosis. 

Treatment: — The treatment should begin with attention to the bowels, 
which should be kept free and disinfected. Apart from this the treatment 
is that of anemia already fully described. The administration of sup- 
rarenal extract may be resorted to with reasonable expectation of benefit. 
While this will not cure tuberculosis of the suprarenals, it must be recol- 
lected that it is by no means certain that all cases of Addison's disease 
are dependent upon tuberculosis. Even if the suprarenal disease be in- 
curable, the function of these glands will be supplied by the extract, and 
great temporary relief will be afforded. The extract should be given 
hypodermically or to be absorbed from the mouth. 

Raven obtained marked benefit from the use of adrenalin, m. 15 to 60 per 
diem, for 11 months. 

INFLAMMATION OF THE THYROID GLAND 

The gland becomes the seat of boggy swelling, single or multiple 
abscesses, the vessels are engorged, and hemorrhages, thrombi and ne- 
crotic areas are found. The cause may be a blow, but the malady gener- 
ally is an incident in the course of an infectious fever, such as smallpox, 
typhoid or malaria. It may occur with rheumatism or be caused by an 
unclean hypodermic needle. 



270 GOITER 

The symptoms are fever, pain, swelling and tenderness, confined to 
one or more lobes. Suppuration follows. The swelling may obstruct 
the veins, causing vertigo, headache, cyanosis and epistaxis. Fatal com- 
pression of the trachea may occur. Suppuration generally ensues, and 
the pus may empty into the trachea or esophagus, or burrow widely. 

The malady should be distinguised from inflammation of the lar- 
yngeal cartilages by the different location. The prognosis is good if the 
pus opens, or can be opened, externally. If the thyroid has been pre- 
viously diseased the case is less favorable. The treatment is surgical. Pus 
should be opened as soon as it formes, while tracheotomy may be necessary. 

GOITER 

In the simple form we have hyperplasia of all the tissues of the 
thyroid gland; in the follicular form the gland elements alone are in- 
creased. In fibrous goiter most of the increase occurs in the connective 
tissue stroma. This may follow thyroiditis. Cirrhotic contraction 
follows in due time. In the vascular form the blood-vessels are enor- 
mously dilated, generally the veins, sometimes the arteries. In cystic 
goiter one or more cysts develop, filled with fluid, which may be colloid, 
mucous or hemorrhagic. Amyloid degeneration affects the vessels prin- 
cipally. Colloid changes are frequent, while calcareous infiltration may 
be seen in very old fibrous goiters. 

Etiology: — Goiter occurs in certain mountainous distrists and also 
in others where the drinking water is highly charged with lime. Heredity 
is strong. It sometimes seems to be epidemic. Women are more liable 
to it than men. It most frequently begins between ten and twenty years, 
and many women date it from pregnancy. 

Symptoms: — There are no symptoms until the thyroid has enlarged 
until it can be seen and felt. The development is usually slow but in time 
may become sufficient to embarrass respiration. One side is generally 
the larger. Sometimes it increases with each menstruation or pregnancy. 

No pain is connected with the gland. The veins over it may 
be swollen and prominent. Less discomfort is experienced if the con- 
nective tissue of the neck relaxes so as to allow the goiter to hang low. 
When pressure causes discomfort it is usually in respiration. Rarely 
patients are affected with headache, somnolence, tetany and convulsions. 
The general health remains good, unless suppuration occurs or the gland 
is disabled by disease. Sudden death very rarely has occurred from 
hemorrhage or pressure on the pneumogastric. 

A loud blowing murmur may be heard in the vascular form. 



EXOPHTHALMIC GOITER 271 

Diagnosis: — The location, shape and course are distinctive. Lym- 
phatic, tubercular, cancerous or sebaceous growths, or Ludwig's angina, 
may easily be distinguised. Thyroid tumors rise during swallowing. 
The course is chronic, the disease rarely shortens life but is not readily cured. 

Treatment: — Persons living in goitrous districts should not drink the 
lime water, or any local water that has not been boiled. Prolonged resi- 
dence in such districts is inadvisable. Vascular goiters may be con- 
tracted by ergot in full doses. The remedy for goiter is iodine, which 
is best used by applying over the skin and driving it in by cataphoresis. 
It should also be given internally in full doses, the best preparation being 
arsenic iodide. Electrolysis is also applied with good results. Old and 
degenerated cases may be benefited by injections of iodine, tapping 
cysts and ligating the thyroid arteries, or the diseased part of the gland 
may be extirpated. The administration of the thyroids of animals has 
proved beneficial and very rarely curative. Considerable reduction of 
size has followed the administration of phytolaccin, alternated weekly 
with arsenic iodide, both pushed to the limit of toleration. 

EXOPHTHALMIC GOITER 

This malady is characterized by tachycardia, thyroid enlargement 
and exophthalmos, with tremors. A number of theories have been 
advanced as to the origin of this disease. Some attribute it to disease 
of the central nervous system, others to disease of the sympathetic nerves, 
while still others look to the thyroid body itself for the origin of the disease. 
Walker has recently advanced the idea that the malady is induced by a 
toxin, formed in and absorbed from the alimentary canal. Whatever 
may be the cause, the disease is manifested by excessive action of the 
thyroid body with consequent overstimulation of the heart and engorge- 
ment of the vessels of the orbit. The disease is therefore exactly the 
opposite of myxedema. The thymus gland is often found to be per- 
sistent. 

Etiology: — It is four times more common in women; may be present 
at any age but is usually found in adults; it is hereditary and especially 
apt to occur in persons with sensitive nervous organizations. Exciting 
causes are emotional shock or stress, severe acute disease and prolonged 
mental or physical strain. It may follow simple goiter, nasal affections 
or pregnancy. 

The disease may develop gradually or rapidly. In the acute form 
we have excessive heart-action, incessant vomiting and purging, and 
marked projection of the eyeballs, sometimes with cerebral symptoms. 



272 EXOPHTHALMIC GOITER 

Lloyd reported a case which proved fatal in three days. In chronic cases 
tachycardia is the first symptom and may long precede the other three 
characteristics. The pulse is always over one hundred and any unusual 
exertion or excitement makes it more rapid, violent and irregular. Pal- 
pitation and dyspnea are common. 

Inspection shows the heart's impulse to be forcible; the carotids and 
abdominal aorta pulsate violently, and pulsation may be seen in the capil- 
laries and veins of the hand. The area of cardiac dullness increases, 
blowing murmurs may be heard at ,the base, while the normal sounds 
are accentuated. The protrusion of the eyeballs varies from time to 
time but tends to become permanent. As the adipose tissue in the orbit 
increases the lids may not reach to the cornea. Graefe called attention 
to the immobility of the upper eyelid when the patient looks down. 
Moebius called attention to inability to converge the eyes on near objects; 
Stellwag, to retraction of the upper lid. Vision is unaffected; the patient 
winks less than usual; the retinal arteries pulsate; irritation and ulceration 
of the cornea may result from inability of the eyelids to cover it. 

Enlargement of the thyroid body may accompany or follow exophthal- 
mos. The enlargement is in the vessels, especially the arteries, and 
fluctuates with the cardiac pressure. Pulsation may be visible, a thrill 
may be felt and a double systolic murmur be heard. Muscular tremors 
occur early, involuntary and fine. Neurasthenia is progressive. The 
mental condition is unstable; sotne fever may occur, occasionally followed by 
profuse sweating. Pigmentation of the skin sometimes occurs, or sclero- 
derma, urticaria, pleuritis or circumscribed edema. Cutaneous resistance to 
the electric current is lessened and the forehead wrinkles are smoothed out. 

Progressive muscular weakness keeps pace fairly uniformly with the 
anemia. Emaciation is a later development. Disorder of the stomach 
and bowels, and hemorrhages, tend to occur as occasional crises, due to 
some slight exciting cause. Albuminuria, polyuria and glycosuria are 
not uncommon. The chest expansion lessens. The heart which is 
stimulated by the excessive thyroid secretion into hypertrophy runs through 
the usual course, reaches the limit of its possible development and spurious 
hypertrophy supervenes, with symptoms indicating a failing circulation; 
the forcible beat shortens, the pulse is not sustained, dropsy appears at 
the ankles and crawls up, dyspnea increases, and portal obstruction is 
manifested with the symptoms caused by passive congestion of its roots. 
The instability of the emotions and the nervous system becomes increas- 
ingly evident. 

Diagnosis: — The four cardinal symptoms— tachycardia, fine muscular 
tremors, exophthalmos and thyroid enlargement, are unmistakable. 



MXOPHTHALMIC GOITER 273 

Even when one or more of these is wanting, as is sometimes the case even 
for a prolonged period at first, the others are too significant to be mistaken 
for any other known disease. An ordinary goiter, flabby and relaxed, 
could scarcely be mistaken for the erectile, pulsating uniform enlargement 
of this malady. 

Prognosis: — If let alone the course is chronic, for several years. When 
the heart has begun to give way the problem is difficult. Periods of 
arrest occur, and these may be permanent. 

Treatment: — These patients do better in moderately warm climates, 
being decidedly worse in winter. An elevation of between 3000 and 4000 
feet has proved beneficial. Cold applied over the thyroid moderates its 
excess, and various hydropathic measures have been found useful in 
•special cases. The same may be said of electricity; in general the sedative 
applications allay the excitement and delay the progress of the malady. 
Anders says that the application of an ice-bag over the heart has admir- 
ably reduced the heart-hurry in some cases, but Weber affirms that 
this is the most effective means known for increasing the force of the 
heart. Rest in bed is always beneficial. The diet should be light and 
unstimulating; alcohol, tea, coffee, chocolate, soups and hot drinks of 
all sorts forbidden. It must be useful in all stages to decrease the cir- 
culatory excitement and pressure by lessening the quantity of blood in 
the body, by the dry diet. 

Anders says that recovery followed the use of digitalis, ergot, strych- 
nine and iron arsenate, for six months, in two cases. These must have 
been advanced to the degenerative period, for while the heart is actively 
hypertrophic such remedies would be perilous. In other cases sodium 
salicylate, sodium glycerophosphate, quinine bromide and other agents 
have been found useful. Thyroid extracts do harm as might be expected. 
The serum from thyroidectomized goats has been recently supplied. In 
one very advanced case the writer has found some benefit from it; not 
much, but as this patient is in the later stages with dropsy, etc., anything 
that gives a little relief is welcome. In the early stages with active hyper- 
trophy the indicated remedy is veratrine, or aconitine if the stomach is 
irritable. Either should be given to exact desirable effect. When the 
circulation begins to fail the less contractile cardiac tonics are often 
the most useful remedies, such as cactin and sparteine, or strophanthin, 
rather than digitalin. 

Total extirpation of the gland is apt to induce myxedema. Bilateral 
resection of the sympathetic nerve has been done with much benefit. 
Starr collected 190 cases where operations had been done; of these 74 
were pronounced cured, 45 improved, and 23 died promptly. 



274 MYXEDEMA 

MYXEDEMA 

This malady follows such disease of the thyroid gland as destroys its 
functional activity. Three varieties occur. 

In true myxedema of adults there is atrophy of the thyroid, and the 
symptoms may be attributed to the lack of the internal secretion supplied 
by this organ. The pituitary body is sometimes affected, and possibly 
this may explain cases of myxedema in which much of the thyroid is 
unaffected. The disease may follow exophthalmic goiter when the thy- 
roid has been exhausted by overstimulation. In most cases the origin of 
the atrophy is unknown. There is some hereditary influence, and women 
are more frequently affected. The symptoms have disappeared during 
pregnancy and recurred after delivery. 

The face is swollen, firm and brawny, the expression lines effaced, 
the skin rough and dry. The facies is dull and expressionless, stupid and 
imbecile. The hair falls, the teeth loosen, the tongue, lips and nose as 
well as the mucosa are infiltrated, and the voice becomes leathery, speech 
slow and measured. Curious nasal explosions occur during speech. 
All movements are slow and coordination requires effort. The infiltra- 
tion is evident in the neck and above the clavicles. It is too firm for 
pitting on pressure. The process extends over the body generally. The 
cerebral functions are likewise performed slowly but correctly. Irrita- 
bility may alternate with hebetude. Hallucination, illusions and delu- 
sions may be present, and the mental disorder may progress to melan- 
cholia or dementia. The symptoms are worse in cold weather. Some- 
times there are disorders of the special senses, paresthesia, occipital head- 
ache, outbursts of temper, and stubbornness. The temperature is apt 
to be subnormal. The excretion of nitrogen is low as metabolism is 
reduced, and sugar or albumin may appear in the urine. 

Sometimes there are hemorrhages from nose, gums or bowels. Ascites 
has been noted. 

The thyroid may be absent. The diagnosis is easy, as edema shows 
pitting. An early sign is an appearance of solidity in the conjunctiva 
(Chapman). The course of the malady is slow, running for many years, 
and death usually occurs from intercurrent maladies. The prognosis 
is good. 

TreBtmetlt: — Patients do better in warm seasons and climates. Warm 
baths are useful. Pilocarpine to full sweating has given temporary relief, 
and strychnine arsenate is a useful 'tonic. But the treatment of this 
disease consists in the administration of thyroid extracts by which the 
lack of the internal secretion is supplied, and the quick relief following 



MYXEDEMA 



275 



attests the correctness of this theory of the disease. As much of the raw 
gland or the extract should be taken as suffices to dissipate the symptoms. 
Begin with small doses and increase as tolerated. Vomiting, renal pain, 
tachycardia, suffusion of the face, syncope, vertigo or headache may 
follow overdoses. Anders says these may be obviated by combining 
arsenic with the thyroid extract. Good results may be looked for within 
a month. The remedy may be gradually decreased as the patient nears 
recovery, but some should probably be taken during the rest of the life, 
at intervals. 

Cretinism: — This is congenital or develops in early infancy. The 
heredity may be from excessive nervousness, syphilis, goiter, or other 
causes of degeneration. It occurs endemically in certain Swiss valleys 
where there have long existed bad hygienic conditions, bad water, and 
constant intermarriages. Goiter here coexists. The cretins are dwarfs 
with large heads and faces, thick lips and tongues, broad bodies and 
limbs, prominent abdomens, myxedematous tissues, umbilical hernia, 
mental defect amounting to idiocy, and physical development retarded. 
The voice is harsh and unintelligible. Anemia with blood of fetal type 
is present. 

Congenital cases usually die soon after birth. Others progress until 
the 15th year, then remain of the childish type during life. Thyroid 
preparations have proved serviceable, and neuro-lecithin would probably 
be a useful addition. 

Cachexia Strumipriva: — The complete extirpation of the thyroid is 
followed by symptoms identical with those of myxedema or cretinism, 
supervening gradually, unless accessory thyroids happen to be present. 
The treatment is the administration of thyroids or of their extracts, 



PART IV 

DISEASES OF THE RESPIRA 
TORY SYSTEM 

I. DISEASES OF THE NOSE 



ACUTE CORYZA 

An acute inflammation of the mucous membrane of the nose, some- 
times extending to the throat, larynx, bronchi, less frequently to the ears, 
or the sinuses opening into the nose. 

Etiology: — There is a predisposition to colds in the head, especially 
in the subjects of chronic nasal catarrh, so that most attacks are simply 
acute exacerbations of the chronic affection. The nasal mucosa then 
appears to be the "locus resistentiae minoris," and it has been held to be a 
safe-guard, as colds settle here in preference to more dangerous localities. 

The exciting causes are exposure to cold or wet, over-fatigue, excessive 
drinking, over-eating, the inhalation of irritant dust or gas, extension 
from pharyngeal or palatal catarrh. The epidemic form is probably 
due to the influenzal bacillus, or possibly at times to some other micro- 
organism. Attacks are often autotoxemic. 

Symptoms: — The attacks often begin with itching in the soft palate, 
or burning in some part of the nasopharyngeal mucosa, chilliness, tickling, 
sneezing, and the discharge of a watery fluid that irritates the membrane 
and skin with which it comes in contact, excoriating the upper lip and 
margin of the anterior nares, and extending the inflammation. Headache, 
weakness, aching of the muscles and tendency to sweating from relaxation 
of the cutaneous tension, are commonly present. The temperature may 
rise to 100-104, the pulse accelerated but compressible, thirst is felt, the 
appetite may be good or impaired, the bowels constipated. The nasal 
passages are closed by swelling, but when the patient lies down the top 
nostril opens, the passage of air along it causing burning. When the 
patient turns over to the other side, in a few moments the under nostril 
closes and the upper one opens. Taste and smell are lost. Herpes around 



278 ACUTE CORYZA 

the anterior nares or lips is common. The secretion becomes turbid, 
purulent, and large quantities of thick yellow muco-pus are discharged, 
sometimes tinged with blood. The acute symptoms subside within a 
week, the discharge gradually drying up. 

Lachrymation and conjunctivitis indicate extension to the eyes, deaf- 
ness and earache to the middle ear by the eustachian tube, cough and 
hoarseness to the larynx, etc. A rare extension is to the frontal sinuses. 
Twice we have witnessed this, in both instances delirium and coma super- 
vening, which continued until calomel had been given to salivation. In 
a third case the symptoms were so alarming that we trephined the right 
frontal sinus, giving exit to offensive pus, with immediate relief. Some- 
times this attack commences with itching in the soft palate; and if the spot 
is touched with tincture of iodine the attack is aborted. 

Diagnosis: — Influenza is distinguished by the greater severity of the 
symptoms, especially the pain and debility, by its epidemic prevalence, 
and by the presence of the characteristic microorganisms. 

Measles may be suspected if the patient is liable and has been exposed 
to this infection, by the accompanying catarrh of the eyes, pharynx, larynx 
and bronchi, and by the crimson, punctate eruption of the pharynx. 

Prognosis: — Gravity lies in the possible extension of the affection to 
the lungs or the frontal sinuses; young, weakly infants and feeble old men 
being in the same danger. 

Treatment: — Clear out the bowels with a brisk purge, adding an emetic 
if the attack is due to over-eating; give camphor, gr. i; quinine sulphate, 
gr. i; atropine, gr. i-i 34; repeated every hour until the effect of the latter 
is manifested by some dryness of the mouth, and again whenever this has 
subsided. Forbid all food and drink, to keep the blood-vessels empty 
and allow the congested capillaries to unload. This may be aided in 
severe attacks by pilocarpine, gr. 1-67 every five minutes till sweating 
freely; or by amorphous aconitine gr. 1-134 every five to fifteen minutes, 
till the pulse is below 80 and congestion subsiding. 

All methods that include the free use of beverages of any sort aggravate 
the malady. Dover's powder gives relief and may break up the attack, 
but it is less likely to do so than the combination recommended, and is 
apt to be followed by severe headache. 

Locally the most satisfactory remedy is petrolatum. In many persons 
the application of this substance limits the spread of the inflammation. 
Melt cosmoline in a teaspoon, being careful not to get it too hot, and pour 
into the affected nostril; repeating as soon as the sneezing recommences. 

If the attack has become established relief ensues when the nose is 
washed out with warm salt water, containing an ounce of distilled hama- 



CHRONIC CORYZA 2 7 <, 

melis to the quart, through the nasal douche, and spraying with fluid 
albolene or vaseline. The inhalation of steam has a soothing effect. 

The patient should be induced to remain in a warm room, the air 
kept moist by evaporation of water. As the attack subsides benzoic acid 
may be added to the petrolatum, gr. 10-30 to the ounce. Plain fluid petrola- 
tum, applied with an albolene atomizer to the nasal mucosa, is a power- 
ful protective when the patient has to go out in the cold air. 

Neither opiates nor cocaine should under any circumstances be 
employed. 

CHRONIC CORYZA 

The nasal mucosa is infiltrated, the connective hyperplastic or 
cirrhotic, with constant secretion of muco-pus. The sinuses may be 
affected. The malady attends autotoxemia. It may be infectious. 

Smell is weak or lost, the hypertrophy at first causes obstruction but 
atrophy relieves this. The decomposing crusts make the breath bad, 
and cause constant extensions of catarrh. 

The secret of successful treatment is the cure of intestinal autotoxemia. 
With this apply europhen in fluid petrolatum daily, and a weak pro- 
targol solution once a week. Wash out the tract three times a day with 
warm soda solution, a dram to the pint of water. This simple method 
will cure curable cases. 

HAY FEVER 

This is a form of acute nasal catarrh occurring in the fall or spring, 
each victim expecting the onset on a special date, or when some particular 
plant is discharging its pollen. The golden-rod is especially obnoxious. 
The affection is more common among men, young or middle-aged, usually 
of wealth and leisure. It is hereditary, more common in city dwellers, 
though worse in the country air. Autotoxemia causes or increases the 
susceptibility. Hypertrophies of the nasal mucosa are frequently present. 

Symptoms: — The attacks begin abruptly, with symptoms of acute 
catarrh of the nose, eyes and pharynx. The discharge usually remains 
clear. The affection is aggravated by exposure to the open air. Some- 
times the catarrh extends to the pulmonary tract. The symptoms persist 
until the flowering season of the obnoxious plant is over or until frost. 
Dyspnea may be asthmatic. 

DlBgtlOSis: — Hay-fever is distinguished by its recurrence with each 
season, the persistence of the first-stage symptoms, and its obstinacy in 
resisting treatment effective against ordinary catarrh. 

Prognosis: — As regards a permanent cure the chances are not good. 



28o EPISTAXIS 

Treatment: — Patients must get out of reach of the causative element, 
and immunity is found by some at the seaside, by others in elevated moun- 
tainous resorts, by others in northern latitudes. Petoskey, in northern 
Michigan, is a favorite resort for Chicago's hay-fever sufferers. 

The chances for relief are better if hypertrophy or other removable 
disease of the nasal mucosa is found. In some instances the cure of such 
local disease has been followed by a cessation of the attacks, the pollen 
no longer finding a congenial habitat. The application of formalin or 
chromic acid, to harden the spongy tissues, has been tried with some suc- 
cess. Begin with a half per cent solution and increase until the desired 
effect is secured. The objection to all irritant applications is that they 
require preliminary cocainization, with the great danger of the formation 
of a drug-habit, the most disastrous of all that afflict humanity. It is 
better to wash out the nostrils with mild alkaline solutions, such as a 
quart of warm water with a dram of soda or salt, and an ounce of 
hamamelis distillate, and then apply a protective spray of fluid petrolatum. 

Some success has ensued from the administration of strychnine arse- 
nate, gr. 1-30, every four hours, increased until the effect of the strychnine 
is manifested. This may require four times the above dose, or more. 
The astringent effect of suprarenal extract has been utilized with some 
success; gr. 5, three or four times a day. Atropine, gr. 1-500, every half- 
hour till the secretion is checked,- is the best palliative, and has no danger 
back of it like cocaine. Possibly the attack could be prevented if the 
prospective patient wore a respirator charged with antiseptics or glycerin 
to prevent the access of the pollen. 

Gleason follows cocaine with 4 per cent antipyrin solution to prolong 
the effect. Hollopeter daily sterilizes the nasal tract by Dobell's solution, 
atomized and then swabbed, plugging the nostrils with cotton saturated 
with menthol in albolene. 

EPISTAXIS 

The causes of nose-bleed are traumatism, nasal maladies, typhoid 
fever or influenza, diphtheria or scarlatina, hemophilia or pernicious 
anemias, vicarious menstruation, rare air, plethora, over-exertion and 
early arteriosclerosis. 

The blood is bright, arterial, and may flow out or be swallowed and 
vomited. Anemia results from fracture at the base of the brain, diph- 
theria and scarlatina. It is a bad omen. 

Treatment: — In ordinary cases the bleeding ceases soon if the nostrils 
are washed out with cold water and compressed till clots form. In diph- 
theria, syringe with chromic acid solutions, increasing strength till effective. 



ACUTE LARYNGEAL CATARRH 281 

Suprarenal solutions may be applied. In obstinate cases plug the nostrils, 
back and front. Cocaine solutions stop oozing. Any astringent relieves 
mild forms. Atropine might be given in bad cases. Clear out the 
bowels. In recurrent cases give calcium lactophosphate, 10 grains daily, 
for a month. YVe believe there is here a certain fragility of the cell-walls, 
and that this is removed by the persistent administration of this soluble 
and assimilable form of lime. This may be continued for a year 
or more. 

II. DISEASE OF THE LARYNX 

ACUTE LARYNGEAL CATARRH 

Etiology: — The causes are those of acute catarrh, exposure to cold 
and wet, inhalation of irritants, and extension from the bronchi below, 
the pharynx and nose above. Measles, whooping-cough and other 
acute infections are attended by laryngitis. Smoking and alcohol- 
drinking occasion an increased liability to it. 

Symptoms: — Cough, hoarseness, pain on endeavoring to talk, stiffness 
and sometimes pain in the larynx, and irritation as if a crumb had lodged 
in the larynx, are characteristic symptoms. The cough is dry, wheezing 
and incessant. Swallowing may be painful. Dyspnea follows if there 
is swelling of the glottis. There may be a little fever, the pulse slightly 
accelerated. The laryngoscope shows the mucous membranes red and 
swollen, dry or covered with a sticky mucus. 

Diagnosis: — Dry cough, and interference with the function of the 
larynx, phonation, are characteristic. The laryngoscope reveals the 
location and extent of the affection. 

Treatment: — Confine the patient to a well-warmed room, and let 
him inhale steam as frequently as possible. Speech must be forbidden. 
Apply a cold compress to the neck over the larynx. Subdue the fever 
with aconitine amorphous, gr. 1-134, every ten to thirty minutes for an 
adult, and stimulate secretion by apomorphine, gr 1-67 at the same inter- 
vals, suspending it on the occurrence of nausea. No other remedy equals 
steam for the cough, and it is unnecessary to add any medicament like 
benzoin. If the irritative cough persists give syrup of yerba santa, a 
teaspoonful every hour or two. Great care should be exercised when the 
patient goes out into the cold air, and a respirator could be worn with 
advantage, especially if the patient does not breathe exclusively through 
the nose. A sweat from pilocarpine, gr. 1-6 at the beginning, with a brisk 
purge and abstinence from food and drink, will usually abort the attack. 



282 CHRONIC LARGNYITIS 

CHRONIC LARYNGITIS 

The mucosa is thickened, ulcerated and the connective hyperplastic. 
This follows the acute form or occurs in public speakers and singers, 
alcoholics, those who inhale irritants. 

The symptoms are hoarseness and cough, with discomfort or pain 
after speech. It is not readily cured. 

The treatment requires rest, avoidance of irritants, clean bowels, sea 
air or pine forests, and the daily use of europhen in fluid petrolatum with 
an oil atomizer, alternated with other local applications of varied com- 
position. 

LARYNGISMUS STRIDULUS 

Spasmodic croup occurs most frequently in children under one year 
of age; rarely after the fifth year. Rickets frequently coexists. The 
attacks may be induced by temper, or by the causes of catarrh. The 
dyspnea is due to adductor spasm from reflex causes. Acute catarrhal 
laryngitis may coexist. 

Symptoms: — A sudden attack of dyspnea occurs, at any hour, with 
crowing inspiration and cyanosis. There is no fever, cough or hoarse- 
ness. The paroxysm lasts but a few moments, and if severe may induce 
general convulsions. It may occur at any hour, several times in the same 
day. The attacks are commonly termed "kinks." and the child believed 
to hold the breath purposely when crossed. 

Occurring in the course of laryngeal catarrh, the child's breathing 
becomes harsh, it coughs and awakes with dyspnea, the attacks continu- 
ing for an hour or more. 

Diagnosis: — Membranous croup is continuous, not paroxysmal, and 
occurs in older children. The characteristic exudation is present in this 
and in diphtheria. 

Prognosis: — The paroxysms are rarely dangerous, though trying 
to the mother. 

Treatment: — A dash of cold water in the face is effective, or cold applied 
to the neck while the child is in a warm bath. Pass the finger into the 
fauces and raise the epiglottis. If the child can swallow, a small dose of 
glonoin, gr. 1-1500 repeated every five minutes, is successful. In pro- 
longed spasms this may be administered hypodermically, or a whiff of 
amyl given. A hypodermic of apomorphine, gr. 1-134, is suitable for the 
catarrhal form, occurring in older children. The treatment advised for 
catarrhal laryngitis is indicated in such cases. A sound spanking is 



EDEMA OF THE LARYNX 283 

effective when the '"kink" is due to temper. Treat the general condition 
and build up the nutrition. Keep the bowels open. Remove sources of 
reflex irritation. 

EDEMA OF THE LARYNX 

This may be due to inflammation from any cause, tubercle, syphilis, 
erysipelas, typhoid fever, diphtheria, or disease of neighboring parts; 
or to general or local dropsy. 

The onset is sudden and severe with dyspnea, aphonia, stridulous 
respiration of rapidly increasing difficulty. The swelling is about the 
epiglottis, rarely below the vocal cords. The swelling may be visible 
with the tongue depressed. The malady is perilous unless prompt relief 
is afforded. 

In inflammation apply ice to the neck and mouth; leech the neck; 
scarify the edematous parts with a bistoury, guarded with adhesive plaster 
except the point. Tracheotomy may be required. 

MEMBRANOUS CROUP 

Morell Mackenzie demolished the old barriers between diphtheria 
and membranous croup. He showed that the differences between the two 
were simply due to the location, diphtheria occurring in the richly vascular 
structures of the pharynx, with abundant glandular connections, croup 
in the thinner membrane stretched over the laryngeal cage, with no lym- 
phatics except Luschka's gland. Croup is not followed by paralysis, 
simply because the little patients do not survive to reach the paralytic 
stage. The two affections occur coincidently, and run into each other, 
diphtheria extending down to the larynx, the croupous membrane up 
to the pharynx. This has now become the prevailing view, especially 
since the Boards of Health, wisely choosing the safer side, have univers- 
ally required the reporting of all membranous croup as diphtheria, con- 
sidering it better to permit no possible case of the infectious malady to 
go at large. 

Nevertheless, it is now becoming evident that there are cases of mem- 
branous croup that are not laryngeal diphtheria, but rather the highest 
manifestation of the inflammatory process. In these the microorganism 
of diphtheria cannot be found, and their causation is that of catarrh rather 
than of diphtherial infection. There is no sharply marked line of difference 
between catarrhal and membranous croup, but cases occur so near the 
border that it is impossible to classify them. The older works give as 



284 MEMBRANOUS CROUP 

the diagnostic signs of the graver malady the presence of fever with 
retraction of the abdomen on inspiration, but such cases occur, even 
necessitating surgical intervention, without any sign of membranous 
formation. 

Membranous croup affects children between the ages of two and 
seven, rarely outside of these limits. Exposure to cold winds and damp 
is the usual exciting cause. "Croupy" children are usually affected by 
catarrhal laryngitis. Those who are housed too closely, in superheated 
flats, strangers to cold baths, rarely allowed to breathe the open air and 
then overloaded with clothing, are the usual victims. 

The affection begins usually at night, with a hoarse croupy cough, 
with dyspnea, the child struggling for breath. The difficulty is most 
marked with inspiration. Examination of the throat may show a few 
white flecks on the tonsils, which increase and coalesce into a thin, white 
pellicle. The hoarseness deepens into complete aphonia and the child is 
seen to cough, not heard. The temperature rises to 101 to 103 degrees, 
the pulse keeping pace. The child lies quiet, the breathing being sufficient 
until he attempts to move, when the suffocative paroxysm at once comes 
on; he struggles for breath, clutches his mother, and finally falls back 
exhausted, when a moment's respite ensues. These symptoms continue 
until morning, when some moderation usually occurs, but as night comes 
on the struggle is renewed. The obstacle to the ingress of air is so marked 
that the abdomen is retracted on inspiration, showing a boat-shaped 
depression. This marks the danger-point. As expiration is less obstructed 
more air escapes from the lung than enters, the air in the tract becomes 
rarefied, and the powerful efforts of the child to draw air through the 
narrowed chink of the glottis cause suction as of an air-pump to be exerted 
on the air-cells. The result is that blood-serum is drawn through the 
delicate walls, and begins to accumulate in the air-cells and bronchioles. 
Its presence is manifested by serous rales, at first fine but growing louder, 
with cyanosis keeping pace with the effusion. The struggles of the child 
become less strenuous, it grows quieter, but the quiet is that of approach- 
ing death from carbonic acid anesthesia. This is the usual cause of 
death, and if surgical intervention be delayed till now it will fail to save 
the patient's life. Even if death does not supervene in this stage there 
would ensue an acute bronchopneumonia, probably resulting fatally. 

In the rare cases ending in recovery the symptoms are prolonged for 
several days, until the membrane is loosened and spit or vomited up. It 
may be reproduced, but this is rare. In one case of the writer's that 
recovered, a strong girl near the upper age limit, with a larger glottic aper- 
ture than usual, paralysis of phonation remained for weeks. 



MKMBRANOUS CROUP 285 

The diagnosis has been already discussed. Catarrhal croup occurs 
in "croupy" children, with little or no fever, no exudate on the tonsils, 
no Klebs-Loeffler bacilli, and yields to emetics and other remedies. In 
diphtheria we may find the characteristic microorganisms, the malady 
begins in the throat, extends by preference up to the nose, the glands 
are early involved, and only secondarily it attacks the larynx. 

The prognosis is of the worst. The older writers refused to believe 
recovery from true croup possible. 

And this serves to illustrate clearly the shocking barbarity of their 
treatment. If the child were bound to die, why torture it with emetics 
of copper, alum, antimony, turpeth, etc ? Why not mercifully let it die 
in peace if die it must? One only fragment of the old treatment is worthy 
of retention — the use of morphine. It will be noticed that as long as the 
child lies quiet the respiration suffices for his needs, and the paroxysms 
of dyspnea occur when he attempts to rise. Give him enough morphine 
to keep him tranquil, but carefully avoid narcotism, which is certain death. 
This reduces the violence of the paroxysms and conserves his strength. 
Then, as death is due to the pulmonary edema produced by suction, just as 
soon as retraction of the abdomen begins to be manifest during inspira- 
tion, intubate. Parents will not object to this at this early stage, as they 
are apt to if tracheotomy is suggested. But this matter of the parent's 
consent has been grossly exaggerated. The physician who does not 
know the necessity for such operation, and knowing this cannot show 
the parents that necessity, ought in pursuance of his duty as a saver of 
life to turn the case over to some one of sufficient force of character to 
compel consent to the duty. Parents have no rights that involve the 
sacrifice of their child's life. 

Within a few years a new remedy for membranous croup has been 
advocated, in a preparation known as calx iodata. It is not a chemical 
iodide of lime, but a loose combination of lime and iodine, the effects of 
which closely resemble those of free iodine. The dose for a child in the 
croup age is gr. 1-3, repeated every five, ten or fifteen minutes, in a tea- 
spoonful of hot water, until the croupal symptoms subside. We have 
many letters from experienced physicians who report almost invariable 
success with this remedy. Its use has also confirmed the views of those 
who believe some cases of membranous croup are not diphtheritic, for 
when the malady has originated in the pharynx as true diphtheria and 
extended to the larynx calx iodata has not proved effective, while calx 
sulphurata has exerted the same powerful control as over other manifesta- 
tions of diphtheria, when pushed to saturation. Be this as it may, the sub- 
sidence of the symptoms of croup in a few hours while calx iodata is being 



286 ACUTE BRONCHITIS 

administered, is something marvelous to one accustomed to the old method 
with its invariably fatal ending. Morphine till abdominal retraction during 
inspiration occurs, then intubation, and calx iodata from the first, given 
with a free hand, are the three remedies for membranous croup — and 
the only three whose effects entitle them to consideration. 

III. DISEASES OF THE BRONCHI 

ACUTE BRONCHITIS 

Acute catarrhal inflammation of the mucous membrane of the trachea 
and bronchi. The affected membrane is red and puffy, exuding a secretion 
at first watery, then cloudy, opaque and finally purulent, gradually 
drying into scabs or crusts. The mucous glands swell, the epithelium 
is cast off, the submucous layers swell, become succulent, and in them 
leucocytes are found in n umbers proportional to the severity of the attack. 

Etiology. — The 'causes are those of catarrhs; exposure to cold and 
wet, inhalation of irritant gases, ammonia or ether, vapor, dust, etc. Usu- 
ally the inflammation begins in the nose or throat and extends to the 
larynx, trachea and bronchi. Preexisting chronic catarrh of any part oi 
this mucous tract renders the individual more liable to attacks. The 
aged and very young, the feeble, uricemics, cachectics, those who are too 
much housed up in superheated flats or unused to exposure, are apt to take 
cold. Changes in the weather cause more or less extensive prevalences, 
and these resemble epidemics if they are not so in reality. Many infec- 
tious maladies number bronchitis in their symptoms or sequels, and in 
nephritis and valvular heart-disease it is often present. 

Symptoms: — The early symptoms are those of a cold, chilliness, aching 
muscles and head, a sense of tightness in the chest, itching in the larynx, 
dull pain under the sternum, fever usually slight but ranging up to 104 
degrees, the breathing somewhat accelerated, especially in children. The 
cough is at first dry and irritative, perhaps severe enough to cause soreness 
at the insertions of the diaphragm, and becomes looser as the attack 
passes the climax and the sputa become purulent and copious. The 
symptoms closely follow those of coryza as regards the secretion. The 
laryngoscope shows the mucous membrane red and swollen, later covered 
with the exudate. Children rarely suffer an initial convulsion. 

The hand placed upon the chest detects some fremitus. Ausculta- 
tion discloses sibilant rales or wheezing in the early stages, gradually 
replaced by mucous and submucous rales, growing larger as the secretion 
becomes freer, with sonorous rhonchi when sticky masses adhere to the 



ACUTE BRONCHITIS 2S7 

sides of the larger bronchi. Rarely there are collections of secretion 
large enough to cause slight dullness. Coughing may alter the character 
of the rales. 

Prognosis: — Bronchitis is dangerous in infants, aged men and very 
feeble, cachectic persons. Extension into the smallest bronchi, with 
dyspnea, sluggishness or cyanosis, are grave symptoms in such cases. 
Ordinarily the attack subsides in a week, the cough and expectoration 
continuing indefinitely. Cachectic patients suffer severely and then the 
malady tends to chronicity. The low grade of sensation in the mucous 
membrane of young infants and aged persons permits the accumulation 
of secretion to a dangerous extent. 

Diagnosis: — The slight fever, absence of crepitus and dullness, dis- 
tinguish bronchitis from pneumonia. The former is bilateral. Pleurisy 
has a history of acute pain on inspiration, is unilateral, has dull- 
ness on percussion, bulging intercostals and loss of respiratory 
movement. In bronchopneumonia the rales are finer, the dyspnea 
worse, respiration rapid, fever higher, and dullness may be found 
in spots. Whooping-cough may be inferred even before the char- 
acteristic whoop, from the cough recurring in paroxysms that 
grow more severe as the catarrhal stage nears its end, the cough 
awakening the child from sleep and continuing until vomiting occurs. 
Measles presents a red, punctate eruption on the fauces and the fever is 
much higher. 

Treatment: — As with nasal catarrh, it is possible to break up an acute 
bronchitis if seen early. Confine the patient to a warm, equably heated 
room, the air moistened by water continually evaporating in it. Admin- 
ister a cathartic, restrict the use of fluids as strictly as possible, and give 
one of the following: 

1. Aconitine amorphous gr. 1-134, atropine gr. 1-500, morphine 
gr. 1-67; given together, and repeated every ten minutes until the physio- 
logic effect of one or other of the constituents begins to be felt. Generally 
it is the atropine, which manifests its commencing toxic action by dryness 
of the mouth. As soon as this is felt the frequency of the doses must be 
diminished to one-half hour, one hour or two hours, the object being 
to keep up the effect but not to exceed it. This has proved most effective 
for anemic, slender persons, but should not be used for uricacidemic 
individuals. 

2. Atropine sulphate gr. 1-500, quinine sulphate gr. 1-6, camphor 
gr. 1-6; taken together every ten minutes till the atropine effect is slightly 
felt, then less frequently so as to keep up this effect but not to exceed 
it; that is, slight dryness of the mouth. This is good treatment for plethoric, 



288 ACUTE BRONCHITIS 

over-fed uricacidemic patients, and those who have weak hearts or a tend- 
dency to constipation. 

3. Pilocarpine gr. 1-67, every five minutes until sweating cr salivation 
begins, then enough to sustain the action just at this point. This is 
especially useful in stout patients with strong hearts, those given to excessive 
water-drinking, free sweaters. 

In all cases it is necessary to forbid fluids, as if the veins are gorged 
with fluid there is little use in trying to reduce the hyperemia of the affected 
tract. The diet should for the same reason be spare. Much benefit is 
experienced in all forms of respiratory catarrhs by keeping the air of the 
room moistened by evaporating water in it, and by prolonged inhalations 
of steam frequently repeated. The mucus is softened and brought up 
and the inflamed membrane soothed by this procedure. 

On the day following, the attack will be broken up but the patient 
relaxed and in favorable condition to contract fresh cold. If it be necessary 
that he should go out this relaxation should first be removed by tonics, 
such as brucine gr. 1-67 every hour or two, till the toning influence is 
manifest; and this should be sustained for several days, with restriction 
of the quantity of food and drink, these being non-stimulating in quality. 

If the patient is not seen until too late to abort the attack, hurry it 
through its stages as rapidly and comfortably as passible. The same 
hygienic and dietary rules are to be enjoined, the bowels kept somewhat 
loose by saline laxatives, the hyperemia moderated by the judicious ad- 
ministration of the ''dosimetric triad," given every half-hour to one or 
two hours as required. Only in pronounced plethorics should the strych- 
nine be replaced by veratrine in like doses. Indeed, the relaxation 
usually manifest in respiratory catarrhs renders the tonics advisable in 
most cases from the first. 

To promote mucous secretion we have three excellent remedies, apo- 
morphine, lobelin and emetine. The first is the most powerful and speedy, 
and suitable to severe forms, in the robust. The dose is gr. 1-67 every 
quarter-hour till faint nausea is experienced, then less frequently. Lobelin 
is a powerful stimulant to secretion, better suited to croupy and dyspneal 
forms. Emetine is applicable to children and weakly patients, where the 
more powerfully depressing remedies might be dangerous if given reck- 
lessly. The doses and administration of lobelin and of emetine are the 
same as of apomorphine. Either should be continued until the mucous 
secretion is loose, thin and yellow. 

To moderate the cough and bring it into harmony with the excretory 
needs of the patient we have likewise three excellent remedies. Codeine 
moderates bronchial irritability more directly than any other drug, with 



ACUTE BRONCHITIS 289 

less interference with digestion. It may be given in doses of gr. 1-24 to 1-6, 
repeated as the case demands. The second is the inhalation of steam, 
The third is patience. To one who has never tried it, it is inconceivable 
how much benefit accrues in the irritative stages of respiratory catarrhs 
from persistently restraining the impulse to cough, until the secretion is 
so loose that slight effort will dislodge it. The cough is largely due to 
the inflammation, consequently is useless and does harm by straining 
the lungs. 

Mild counter irritation to the chest is of value, and the practician may 
choose between ammonia liniment, mustard mitigated with flour or molasses, 
or the cold compress covered thickly with dry, warm flannel. Each has 
its advocates and each is of value. Cold applications have 
proved unserviceable with us in treating uricemic, plethoric persons, 
especially those who catch cold easily. 

As the attack progresses through its stages it may run into bronchorrhea, 
with free serous secretion. It is probable that in these cases the pul- 
monary tract has been invaded by a swarm of microorganisms, and the 
thin, watery secretion is a culture-fluid of these. The remedies for this 
condition are the inhalation or atomization of tar-water, and cubebs, 
myrrh, copaiba, balsam of tolu or Peru, benzoic acid and its salts. Benzoic 
acid and cubebin, gr. 1-6 each, every ten to sixty minutes, are as useful as 
any, unless it is copaiba, which may be given in capsules, m. v. every two 
hours in obstinate cases. Strychnine, gr. 1-30 every two to four hours, 
is also advisable to increase the tonicity and resistance of the bronchial 
tissues. The diet should be the more nutritious as any form of chronic 
bronchitis threatens to become established. But in every case the sputa 
should be repeatedly examined to see if some microbic infection has not 
occurred. 

If the catarrh tends to become dry, with scanty secretion, it may require 
stimulation with lobelin; or Murrell's advice may be followed, of applying 
wine of ipecacuanha locally with an atomizer. But if dyspnea attends, 
with irritative cough and difficult breathing, the sensory respiratory nerve 
may be sedated by atropine gr. 1-500 every five to sixty minutes till the 
effect is manifested. This will be hastened by combining glonoin in like 
doses; or aspidospermine may be employed, gr. 1-12 every five to thirty 
minutes, or iodoform, gr. 1-6 every ten minutes. 

In elderly patients the sensibility of the respiratory mucosa is slight, the 
tissues relax, and the impulse to cough is not felt. Secretions collect in 
the bronchi until the patient becomes dull, cool, cyanotic, the rales may 
be heard before entering the room, and the patient is literally drowning 
in his own secretions. The remedy is an emetic of seidlitz powder, the 



2 9 o CHRONIC BRONCHITIS 

acid solution being first swallowed and then the other, which will empty 
the stomach more quickly than any other emetic and without nausea or 
depression. Follow this with sanguinarine nitrate, gr. 1-67 every half to 
two hours, which will stimulate sensation and make the patient 
cough harder. 

Infants with bronchitis also have little sensibility in the mucous mem- 
brane, and care must be taken that the secretion is raised. Somnolence, 
blueness about the lips, pallor, shallow respiration with little or no cough, 
should excite uneasiness but are apt to be overlooked by an inexperienced 
mother. An emetic will rid the chest of mucus but further lowers the 
vitality. Sanguinarine in doses appropriate to the age is of value, also 
strychnine pushed to the physiologic limit. Place the babe in a- hot bath 
and dash a little cold water on the chest to excite crying and full respiration. 
If emetics are given it should be only at night, that the respiratory tract 
may be freed from mucus before the parents settle for sleep. Opiates 
should rarely be administered to infants and never when subject to bron- 
chitis. Uricemics, cachectics, and persons addicted to the immoderate 
use of beverages, are especially subject to bronchitis and other respiratory 
catarrhs. Ice-water fiends are especially liable, as their constant per- 
spiration renders them susceptible to every draft. This should be taken 
into account in seeking to lessen the vulnerability to colds. , Patients should 
be restricted to their rooms until well over the attack, and be well protected 
when they go out. 

CHRONIC BRONCHITIS 

Under this term are grouped a number of affections differing as to 
their causes and as to their pathologic conditions. The mucous mem- 
brane may be denuded of its epithelium, thin, the longitudinal elastic 
fibers hypertrophied, the glands and muscular fibers atrophied, the bronchi 
dilated into bronchiectases; or the mucous structures may be infiltrated 
by spurious hypertrophy, the interglandular connective tissue hyper- 
plastic and the surface granular. Follicular ulceration is not uncommon 
while the atrophied tissue may be in part replaced by emphysematous 
dilation of the air-cells. 

Etiology: — Chronic bronchitis may follow repeated acute attacks; 
underlying it we may find a cachectic or diathetic state, rheumatism, 
scrofula, uricemia, alcoholism, syphilis or nephritis. It occurs in the 
mechanical congestion of the lungs from obstructive disease of the heart. 
Primarily it occurs from habitual exposure to cold or wet, or the inhalation 
of irritant vapors or dust. It is common in old age. It is worse in winter, 



CHRONIC BRONCHITIS 291 

in wet seasons, when sudden changes occur in the weather, and during or 
after epidemics of influenza. It tends to subside in the summer, reap- 
pearing earlier each fall and lasting later each successive spring. 

Symptoms: — A sense of weight may be felt in the chest. If the mucus 
is adhesive or abundant the cough may be so violent as to cause soreness 
from straining the insertions of the diaphragm. The accessory muscles 
of respiration, the sterno-cieido-mastoids, scaleni, etc., in time become 
hypertrophied by the violent coughing, and stand out plainly from the 
shrunken tissues around them. Cough is more violent if the secretion 
is in the larynx or the smaller bronchi. It is less marked in old age when 
the bronchial sensibility is low and secretions accumulate. When chilling 
or other causes induce an exacerbation of the malady the cough is worse. 

The sputa may be thick, scanty adhesive mucus, free muco-pus, starchy 
or gelatinous, dried greenish scabs, decomposed fetid plugs, or the serous 
discharge of acute mycosis. There may be a little fever towards evening, 
but this symptom usually indicates an acute attack or extension of the 
inflammation into the lung-tissues. The health may remain good for 
years, digestion fair, sleep disturbed by cough. The tendency is for the 
the malady to extend. Dyspnea may be marked, or wanting. 

The thorax expands, the respiratory movement is limited in range. 
The percussion sound is clear while auscultation gives rales of every degree 
of fineness and coarseness depending on the mucus present. Often loud 
bubbling is heard over both lungs, the patient coughs up a mass of sputa, 
and then the sounds cease. The vesicular sound is apt to be weak, rough, 
expiration prolonged and wheezing. Dullness on percussion indicates 
edema, pleuritic effusion or invasion of the lung-substance. 

In the aged the most common form is winter-cough, occurring earlier 
each autumn and staying later each spring. Emphysema, dyspnea worse 
on exertion, sometimes cardiac disease or weakness, may be present. 
The sensibility of the mucosa is dulled, and the sputa may be retained 
until decomposition occurs, with fetid sputa, toxic inflammation of the 
bronchi and lung-tissue underneath, fever, somnolence, sapremia, car- 
bonic poisoning and sometimes unexpectedly sudden death. 

In bronchorrhea there is a very profuse discharge, of serum if colli- 
quative or mycotic, of mucopus in late stages of the malady. Greenish 
masses of more consistence are discharged from the dilated bronchi. 

Fetid bronchitis may develop in any case if the secretions are not coughed 
out. Acute septic inflammation ending in ulceration of the surfaces bathed 
in the decomposing secretions follows,or pulmonary gangrene may ensue, 
or empyema from perforation or extension to the pleura. In simple fetid 
bronchitis the sputa on standing separates into three layers, frothy mucus, 



292 CHRONIC BRONCHITIS 

a serous liquid and a thick sediment, containing yellowish masses termed 
"Dittrich's plugs." These contain numerous microorganisms, especially 
the leptothrix pulmonalis, with fat, margarin crystals and pus-cells. The 
general symptoms are grave — rigors, chills, septic fever, rapid weak pulse, 
heavy sweats and rapid prostration of the vital powers. If the irritating 
products reach healthy mucous surfaces great irritation and violent cough- 
ing ensue. The result depends entirely on the treatment. 

In dry forms of catarrh the secretion is scanty and adhesive, the cough 
incessant and dyspnea often marked. Emphysema is a common con- 
comitant. The rales are dry, sibilant, and sonorous. This is the most 
frequent in elderly subjects, the thin, dried-up species. 

Elderly women are liable to chronic bronchitis, beginning early in 
life with slight symptoms, morning cough, little expectoration, no special 
physical signs, becoming worse with years. Uricemia or scrofula may 
underlie. Anders mentions a case where bronchitis and eczema alter- 
nated in an arthritic woman. 

Diagnosis: — Phthisis is distinguished by the history, the loss of flesh 
and strength, fever, signs of disease localized (usually at the apex), and 
the presence of bacilli in the sputa. 

In pure emphysema there is increased clearness on percussion, weak 
vesicular sounds, dyspnea increased on exertion, obstruction of the pul- 
monary circulation if extensive, dilation of the clavicular or intercostal 
spaces, and the history and cause of that malady. 

In pulmonary abscess the sputa contain shreds of elastic fiber, crystals 
of hematoidin and cholesterin, blood-pigment masses, and the site of the 
abscess is denoted by dullness before evacuation, cavernous sounds after- 
wards. No elastic fibers are found in gangrene, the ferment present caus- 
ing their solution, but the prostration is extreme. Bronchiectases are 
usually on one side only; the physical signs of a cavity are present, the 
history pointing to this rather than to tuberculosis, and the sputa examin- 
ation confirming the diagnosis. 

Prognosis: — The victim of chronic bronchitis rarely recovers unless 
he removes to a suitable climate in the tropics. The malady may not 
shorten life, unless emphysema or heart-disease supervenes, or a microbic 
invasion carries some disease into the lung-structures. 

Treatment: — The patient should live in a land of perpetual summer, 
Some protection is secured by hardening the skin, by daily cold baths or salt 
rubs, wearing wool exclusively, night and day, summer and winter, outside 
and inside, head to feet; in fact the " Jaeger system" in its entirety. The 
avoidance of exposure to cold and wet should be inculcated as a duty. 
Epidemics of influenza must be escaped with the utmost speed. The 



CHRONIC BRONCHITIS 293 

inhalation of irritants must be avoided; crowded halls, smoky saloons, 
overfilled cars on damp, humid days, being common causes of acute ex- 
acerbations. Patients with profuse purulent secretion should be sent to 
the pine woods, those with scanty tough sputa to the seaside, while anemic 
cases with serous bronchorrhea should ascend to mountain resorts. In 
all cases an equable temperature should be sought. The hot, dry plains 
of Arizona suit cases with free secretion, while the Florida coast offers a 
suitable site for dry catarrhs. Among the islands of our Philippine pos- 
sessions and in Porto Rico ideal locations could be found for all classes 
of sufferers with chronic pulmonary complaints. 

Coexistent disease of the heart, lungs or kidneys, should receive ap- 
propriate treatment. 

Much may be done by judicious diet and constitutional treatment, 
especially in diathetic cases. In uricemia the enforcement of the vege- 
tarian regime, with the alimentary canal kept free by saline laxatives, 
aseptic by sodium or calcium sulphocarbolate, gr. 5 three to seven times 
a day, the eliminatives active by colchicine, gr. 1-134 two to six times a day, 
with full exercise, will greatly enhance the effect of direct medication. 
In scrofula, tuberculosis, cachexias generally, where there is a basal fra- 
gility of the cell-walls and consequent disposition to fall into disease easily, 
with little power to set up healthy repair, calcium salts are indicated, the 
sulphocarbolate as an intestinal antiseptic, the lactophosphate in similar 
doses to restrain colliquative discharges; the sulphide, gr. 1-2 every hour 
or two to check pus-formation; the hypophosphite, gr. 1-12 every waking 
hour as a tissue-builder, for months or years if necessary. 

Anemia is best met by iron arsenate, gr. 1-67 and iron phosphate, gr. 1-6, 
repeated every waking hour. 

When the secretions are scanty and dry the best remedy is the inhala- 
tion of steam, with lobelin or emetine internally, gr. 1-67 to 1-12 every 
waking hour, stopping when the desired effect is manifested or nausea 
supervenes. 

If the secretion is profuse and purulent, calcium sulphide, gr. 1-2, 
strychnine arsenate, gr. 1-67, and macrotin, gr. 1-6, should be given to- 
gether every waking hour till full effect, as indicated by the odor of sulphide 
on the breath, slight strychnine twitching, or physiologic tonicity of the 
the heart from the macrotin. The latter with the strychnine is intended 
to tone the relaxed mucous tissues and check the abnormal output of se- 
cretion. Possibly hydrastine gr. 1-67, added to each dose, would aid in 
this respect. 

If the secretion is serous and profuse, there may be a general broncho- 
pulmonary mycosis present, or the flow is colliquative, alternating with 



294 CHRONIC BRONCHITIS 

a similar flow from the skin or the bowels. In the former cases calcium 
sulphide must be pushed to full toleration, with iodoform, gr. 1-6 to i every 
hour, to destroy the microorganisms; while sprays of europhen in fluid 
petrolatum, one part to eight, preceded by complete cleansing of the pul- 
monary tract by five minutes' inhalation of the fumes of boiling vinegar, 
should be repeated every two hours. Other antiseptic sprays have not 
given as good results, though one of camphor and menthol 23 grains, 
thymol 71-2 grains, and fluid petrolatum 1 oz, has often proved a valu- 
able adjuvant. Strychnine to full tolerance, a highly nutritious diet, the 
air of the room charged with the vapor of the oil of cloves are also in- 
dicated. 

When the bronchorrhea is colliquative the fever should be checked 
by calcium sulphocarbolate gr. 5, every hour or two, with equal doses of 
calcium lactophosphate which is almost a specific here, and guaiacol 
externally, five to ten drops diluted with cod-liver oil rubbed into the skin 
over the lung. The body should be sponged with vinegar. Strychnine 
is required in full doses, with macrotin gr. 1, every two to four hours. 
This powerful stimulation of tonicity will generally rouse the failing powers 
and keep the patient alive a while longer. And in these cases he wants 
every hour of life he can secure and is grateful for every day that he is kept 
alive, though death's pinions hover over him continually. 

When the sensation of the bronchial mucosa is lost and the secretions 
collect, with cyanosis, drowsiness, etc., sanguinarine is the most effective 
remedy in doses of gr. 1-67 to 1-20, every one to two hours, until the pa- 
tient is coughing sufficiently to rid his tubes of the redundant secretions. 

If on the contrary the cough is excessive and there is little or no secretion 
to be expelled, the sedatives are required, codeine gr. 1-12 to 1-6; zinc 
cyanide gr. 1-67 to 1-20, the best and most manageable of the cyanide 
remedies; or Dover's powder as modified by substituting camphor 
monobromide for potassium sulphate and the alkaloids for opium and 
ipecac. The inhalation of steam is again a most essential remedy. Mur- 
rell advises spraying with wine of ipecac. We have utilked the suggestion 
but substituted a watery solution of emetine instead, gr. 3 to 1 oz. of water. 
The atomization of fluid petrolatum is also very soothing. A full dose of 
atropine, gr. 1-134, will often check the irritation, especially if the presence 
of marked dyspnea indicates the predominance of the spasmodic element. 
Counter-irritation over the pneumogastric nerve in the neck also often 
gives great relief. 

Of the remedies usually administered for bronchitis very few are given 
with a definite idea of their true effects. A mixture is made of a number 
of the so-called expectorants, often antagonistic; these are swallowed at 



BRONCHIECTASIS 295 

lengthy intervals, until time has cured the patient or established the chronic 
malady. Ipecacuanha and cocillana relax the congested tissues, lessen 
hypersensitiveness and promote secretion. Squill and senega increase 
sensitiveness and aggravate the cough, increasing congestion. Tolu, 
copaiba, myrrh, the balsams and cubebs, check secretion, leaving an acute 
congestion unrelieved, but are effective in restraining profuse mucopurulent 
discharge. They have some effect also in clearing away the " dregs" of 
an attack, when it threatens to become chronic. Sugar, licorice, gums 
and mucilages, soothe pharyngeal irritation. I have given ammonium 
many times and have found no place for any of its salts that is not better 
filled by the agents above mentioned. 

In fetid bronchitis the volatile oils are of great value, stimulating the 
imperiled tissues to fight off impending death. Oil of turpentine, eu- 
calyptus, cajeput or sandal, should be given in doses of one-half to one 
gram (seven to fifteen minims), in capsule every one to three hours. Whether 
these agents are actually capable of stopping a pulmonary gangrene once 
begun is perhaps doubtful, but there is no more effective treatment known. 
Strychnine arsenate should, however, be pushed to full toleration, gr. 1-30 
every one to three hours; the richest diet is to be ordered that the patient 
can take. Sprays of phenol 1-2 to 1 per cent in distilled water, should 
also be used often enough to prevent fetor of the breath. 

Pulmonary gymnastics may be of great value. 

BRONCHIECTASIS 

Two forms of bronchial dilatation are found, the cylindric and the 
saccular. The dilated tubes form sacs, with smooth walls, communicating 
to form compound cavities, of all sizes. The cylindric epithelium lining 
normal bronchi is replaced by tesselated cells. The subepithelial tissues 
atrophy. Secretions lying in these cavities decompose causing irritation, 
inflammation, ulceration and the symptoms consequent. 

Etiology: — Whenever a disease exists in the thorax that causes de- 
struction of a part of the lung-tissue or its compression, nature supplies 
the vacuum by drawing in the intercostal spaces, approximating the ribs, 
dilating the air-cells or the bronchi. This process therefore may follow 
pleurisy with permanent compression of the lung, pneumonia or tuber- 
culosis with destruction of tissue, chronic bronchitis with atrophy, and 
lobular pneumonia with atelectasis. The weakening of the bronchial 
walls by disease favors dilation. Straining from whooping-cough is more 
likely to produce emphysema, though Heubner thinks this affection and 
measles sometimes cause dilation. Rarely the malady is congenital, but 



296 BRONCHIECTASIS 

in such cases the true cause is probably lobular pneumonia. Bron- 
chiectasis is more common in male adults. 

Symptoms: — The symptoms depend on the presence of fluid in the 
sacs. If there is none, the only symptom may be shortness of breath, 
dependant on the quantity of pulmonary tissue destroyed. More fre- 
quently bronchiectasis is simply an incident in the course of the causal mal- 
ady, whose symptoms are present. If the cavity fills with fluid it is apt 
to cause irritation and persistent cough until emptied. The sputa are 
characteristic of cavity-retention, and are separable in layers. Some- 
times there is little sensibility and the cough only occurs when the patient 
lies down or turns to the sound side, when the contents of the cavity begin 
to flow into the trachea and are coughed up. Cavities may exist on both 
sides and be thus emptied successively. The sputa may decompose if 
long retained. The consequent ulceration may then cause hemoptysis. 
Retained sputa consist of mucus, pus-cells, Charcot-Leyden crystals, 
fat-crystals in bundles, leptothrix, vibriones and various bacteria. Elastic 
fibers indicate ulceration and destruction of the pulmonary parenchyma. 
The chest wall is usually retracted. Percussion is flat, dull if the 
cavity is filled, tympanitic if empty, abnormally clear sometimes from the 
accompanying emphysema and air in the cavity. Auscultation gives a 
weak vesicular sound, and various moist rales dependent on fluid present. 
The majority of pulmonic cavities are, at least in the beginning, bron- 
chiectases. 

BRONCHIECTASIS 

History of chronic bronchitis, pleurisy or other malady with 
diminished thoracic contents. 

Cough paroxysmal, • ' 

Sputa of cavity, copious, 

No tubercle bacilli, 

General health good, 

Little or no fever, 

Long course, 

Persistent, quiet, located near base posteriorly. 

TUBERCULAR CAVITY. 

History of attack, emaciation, sweats, hectic, predisposition, 

infection, 

Cough morning and evening, nummular sputa, 

Tubercle bacilli, 

Progressive debility, 

Fever, 

Shorter course, 

Progressive; near apex. 

Empyema with pneumothorax has the history of pleurisy with sudden 
discharges of much purulent sputa at long intervals. Actinomycosis 
is diagnosed by the microscope. 



BRONCHIAL STENOSIS 297 

Prognosis: — That of the causal malady. The supervention of tuber- 
culosis or of streptococcus-infection is disastrous. 

Tredtmetli: — The treatment is of the causal infection. The cavity 
should be kept as clean and as nearly aseptic as possible, by the inhala- 
tion of steam medicated with benzoin, phenol, turpentine, thymol or cam- 
phor, and atomizing fluid petrolatum with europhen, 1 to 8, afterwards. 
Iodoform, terebene or eucalyptol may be given internally with benefit. 
The cavities have been injected with iodine or silver solution through the 
chest-wall, and drained by the surgeon, with great advantage. 

BRONCHIAL STENOSIS 

The bronchi may be narrowed by constriction in the walls, 
or compression from without. Foreign bodies, polypi, pulmonary 
growths and exudates, aneurisms, cysts, tumors, enlarged glands, 
abscesses and pleural effusions are among the causes. The 
pressure induces dyspnea in proportion to the importance of the bronchus 
compressed. The dyspnea is persistent and progressive until the cause 
is relieved. A similar condition obtains to that seen in croup, the air in 
the obstructed region being rarefied, and the affected part retracted on 
inspiration. Other symptoms depend on the causal disease. Edema 
and hyperemia of the obstructed lung follow as in croup. The respira- 
tory movement and tactile fremitus are lessened, percussion clear, vesic- 
ular sound diminished, serous rales supervene with the oedema. The 
diagnosis is made from the limitation of the physical signs, the history of 
the antecedent affection, and the absence of tracheal or laryngeal symp- 
toms. The prognosis is generally bad. The treatment is that of the 
cause. It is obvious that bolder surgery will be the rule than in the past 
history of such maladies. 

ASTHMA 

A neurosis, consisting of paroxysms of spasmodic contraction of the 
bronchioles, causing dyspnea. This is pure asthma, but we often find 
hyperemia, mucous exudations, affections of the nose or throat, emphy- 
sema, cardiac lesions, gout, rheumatism, syphilis, nephritis, and medullary 
lesions accompanying asthmatic seizures. 

Etiology: — A peculiar predisposition exists, as many with similar 
lesions are not asthmatic. This malady is often hereditary. Toxemia 
supplies the irritant, the affected nerve endings being the points of lowest 
vital resistance. Among exciting causes may be named bronchitis (cause 



298 ASTHMA 

or effect), the inhalation of irritants, vapors, dusts, fogs, animal or plant 
exhalations, and all sorts of emotional excitement. Asthma is more 
common in males and the paroxysms occur more frequently in cold weather. 

Symptoms: — Prodromes occurred in one-half of Salter's cases, such as 
emotional vagaries, headache, neuralgia, vertigo, somnolence, vasomotor 
tension with diuresis and digestive disorders. Autotoxemia accounts for 
most of these. The attack usually occurs during sleep, tending to recur 
at the same hour. The symptom is, dyspnea, wheezing for breath, the 
patient feeling as if the air entered the lungs just so far and then stopped. 
He struggles for breath, becomes pale or cyanotic, livid, temperature 
subnormal, pulse weak and fast, cold sweat, great depression, feels as if 
about to die, but never does so in simple asthma. 

The chest becomes rounded, the respiration falls to 12, its rhythm 
is disturbed, inspiration short, expiration prolonged. The diaphragm 
is lowered and expansion limited. Palpation gives normal results and 
percussion shows the chest to be hyperresonant, especially if emphysema 
is present. The wheezing expiration is audible at a distance, with dry 
rales until near the close of the paroxysm, when serous rales are heard 

The paroxysms last minutes, hours, days or weeks, with diurnal remis- 
sions, They end abruptly with expectoration of mucinous molds of the 
small tubes, known as Curschmann's spirals. Leyden's octahedral 
crystals are often present in the sputa, and very large numbers of eosin- 
ophile leucocytes. These are found in excess in the blood during the 
attacks. Later the sputa contain pus. 

Diagnosis: — The history of previous attacks, absence of evidences of 
structural disease, abrupt cessation of the paroxysms, inspiratory dyspnea, 
and the presence of the spirals in the sputa, are clearly diagnostic. 

Prognosis:— Death rarely if ever occurs from pure asthma. The 
paroxysms recur at regular intervals, a group of nightly attacks being 
followed by long exemption. Chronic bronchitis and emphysema are in 
time developed, when the malady may become practically continuous. 
Complete recovery is also very rare, unless the patient removes to a suitable 
climate. 

Treatment: — An emetic or cathartic may relieve the paroxysm by 
removing the cause. The most speedy relief ensues from a counter- 
irritant or ice, applied over the pneumogastric nerve in the neck; or from 
glonoin, gr. 1-250, atropine, gr. 1-500, and strychnine arsenate, gr. 1-134, 
given together every fifteen minutes till relief ensues. Very many other 
remedies have proved effective in relieving the paroxysms, including 
nauseants, antispasmodics, stimulants, anesthetics, analgesics and others, 
many acting through suggestion. The use of chloroform, alcohol, mor- 



ASTHMA 299 

phine and other habit-drugs, affords prompt relief, and as the paroxysms 
surely recur, causes dangers infinitely greater than the asthma. They 
are unnecessary and should never be used. 

When the paroxysms are prolonged, continuous or quickly recurrent, 
the patient should be brought under the full influence of strychnine arse- 
nate. This may require doses of gr. 1-30, repeated three to ten times a 
day, till the full effect is manifested and the malady controlled; and this 
effect should be sustained until it is found that the doses can be gradually 
lowered without recurrence of the paroxysms. Maximal dosage has 
been sustained for weeks with the best results. The use of this remedy 
in moderate doses, increased carefully but fearlessly, offers the best known 
means of breaking up the disease and effecting a permanent cure. Of 
course this does not refer to accompanying organic maladies, each of 
which requires its own treatment. The bowels, kidneys, diet, personal 
and domestic hygiene, should also be regulated. 

When the causes of the paroxysms are known they must be avoided, 
for habit is potent here as elsewhere. If any climate is asthmatic for an 
individual he may have to choose between continuing to be asthmatic, 
and finding a climate where he will be free. Individual idiosyncrasy 
rules here. The smoky air of Pittsburg may be better for some persons 
than the pure air of Chicago. 

Emphysematous cases and those accompanied by heart-disease are 
benefited by potassium iodide in full doses, gr. 40 or more daily. The 
theory that regards asthma as the local manifestation of a general toxemia 
leads to investigation of the causes of toxemia. In one case this proved 
to be a pelvic abscess, whose removal was followed by a cure. Fecal 
retention and defective renal elimination should be relieved. Patients 
are too apt to settle to niter paper or nostrums and chronic invalidism. 

The pathology that is based solely upon post-mortem findings is imper- 
fect, in that it deals only with completed processes that have resulted in 
the extinction of life. As we are somewhat fond of saying, it has to 
do with the ashes of a burned-out fire. To us as physicians the greater 
interest centers in morbid processes that have not as yet passed the point 
at which recovery is impossible. Morbid anatomy can -not take into 
account any of these functional alterations that are not yet expressed in 
permanent lesions recognizable in the cadaver. 

The study of the evidences of disease as presented in the living subject 
is, however, difficult, and imperfect as our knowledge of normal physiology 
is by no means complete. Even in that easiest of all regions to examine 
the abdomen, we are confronted by Tait's brutal dictum — "if you want 
to know what is the matter with a woman, cut her open and find out." 



300 ASTHMA 

As the study of definite, uniformly-acting remedial agents progresses, 
we should have an inestimable means of verifying the conclusions reached 
by clinical study and physical examination. As we know positively 
what these drugs will do, we may prove our conclusions and correct them 
by applying the therapeutic tests. From this standpoint we present 
some consideration on that opprobrium of medicine, asthma. 

The wretched thing 1 It does not kill — usually. It presents no oppor- 
tunity for surgical intervention — the boldest surgeon has not yet resected 
the vagus. It is simply a functional neurosis, without adequate anatomic 
basis, and yet we are hopeless before it. In fact, few patients bother the 
regular physician about it, having long since found him impotent. They 
burn powders, quack, and fly over the earth in search of a climate where 
the breath of life can be drawn in comfort. 

The classic descriptions of asthma do not fit the cases that come to 
the writer. There are no paroxysms occurring at night and leaving 
the patient free after a period of suffering. Instead of that we have a 
patient who, at any time of the year, catches cold. It's a small affair, 
only instead of running the ordinary course, like whooping-cough it 
gets worse when it ought to be getting better. There is scarcely any 
sputa, and very little froth, no sputa cocta forming. The cough grows 
large until the patient seems to be coughing herself to pieces. The cough 
brings on dyspnea, relieved by smoking. The dyspnea comes oftener 
and lasts longer, until it is continuous and so remains for weeks without 
intermission save what may be afforded by treatment. 

Spasm of the muscular fibers of the smaller bronchioles? Can spas- 
modic muscular contraction persist for weeks? Is it not in its essential 
nature paroxysmal? The most skilful clinicians fail to detect any lesion 
or disorder of the heart that would warrant us in classifying this as a 
cardiac asthma. The symptoms culminate in a condition that strik- 
ingly resembles a double pneumonia but with no fever. At the height, 
the diagnosis of general pulmonary fibrosis seems fully justified.. After 
some weeks in bed the grasp of the demon relaxes and recovery ensues, 
still closely resembling true pneumonia. The sputa have shown mean- 
while a few strep to- and staphylo-cocci, and the diplococcus always pres- 
ent in the saliva. 

Constipation, autotoxemia, bad breath and indigestion are always 
present, and the daily elimination of solids by the kidneys rarely reaches 
600 grains. Every meal, every development of flatulence, is followed 
by aggravation of the dyspnea. In the lighter stages the patient may 
be easy while sitting up, but the cough and dyspnea follow exertion, and 
occur whenever she lies down. 



ASTHMA 301 

Now let us see how the spasm theory is confirmed by the results of 
precise medication. We have in atropine a certain sedative for pneu- 
mogastric irritation; we give this agent until the mouth is dry, even 
until the face begins to redden, but there is no relief. Then it cannot 
be pneumogastric irritation we are treating. Take up the hypo- 
thesis of muscular spasm, and nauseate to full relaxation with lobelin. 
Can any such spasm resist that? We know it cannot — but this does. 
Force a free mucous secretion of the respiratory mucosa, with apomor- 
phine (given by stomach so as not to nauseate), and still no relief. The 
old antihysterics, valerian, asafetida and similar agents are absolutely 
powerless here. There is no excess in vascular tension to indicate the 
powerful sedatives, and in fact the pulse is feeble and soft. Morphine 
in small doses fails, in full doses may afford a few hours* sleep or induce 
narcotism, but the following headache is so intense that the patient rather 
endures the loss of sleep that drives her to desperation. All hypnotics 
fail, even hyoscine. Every therapeutic attack based on the spasmodic 
hypothesis proves unavailing. Chloroform and ether anesthesia, like 
the ethers and alcohols by the stomach, add to this long list of failures. 
The only relief comes from smoking saltpeter and stramonium, and the 
dyspnea recurs more and more frequently, the relief is less decided and 
lasting. 

Glonoin gives relief. W T hy? If it were as an antispasmodic, others 
of that group should do so, but they don't. If it be by relaxing vascular 
tension — there was none apparent and veratrine should prove even better. 
There is a little relief from the latter, but not commensurate with the 
depression it here causes, unless guarded by strychnine. But the glonoin 
relief is too sure and decided to be accidental, and we may find some 
light by studying this fact. Primarily glonoin acts by relaxing vascular 
tension. This may give relief — it usually does — by thus opening a way 
for blood to flow out of congested areas. Its action seems to be on the 
terminal arterioles and capillaries, since it does not depress the force of 
the heart like aconitine, and hence we get relief from glonoin which we 
cannot secure from directly stimulating cardiac inhibition. Can we 
correlate with this the relief obtained by smoking? This is not at all 
due to relaxation such as follows tobacco smoking in persons not inured 
to that poison. Relief ensues quickly after a few inhalations of the smoke 
and is not attended by nausea. It follows smoking stramonium and 
niter, or the latter with ordinary insect powder, but not smoking tobacco 
to nausea. 

The remedial effect seems to be due to direct stimulation by the local 
action of the smoke in the pulmonary alveoli or bronchioles. But if relief 



3 02 



ASTHMA 



is due to local stimulation, and to the glonoin peripheral dilatation, how 
can the condition be one of spasm, either direct or local, of the muscular 
fibers or of the nerves, peripheral or centric? It begins to look as if 
we are dealing with a condition of paresis instead of spasm. 

We shift our hypothetical stand from spasm to the vasomotors, and 
will apply our therapeusis to an assumed local vasomotor paresis in the 
affected region. Those who are accustomed to the use of active prin- 
ciples employ as every-day remedies two important triad combinations. 
Burggraeve's dosimetric triad contains aconitine and strychnine arsenate, 
half a milligram each, and digitalin a milligram. Abbott's defervescent 
triad contains half a milligram of veratrine instead of the strychnine 
arsenate. The former is more powerfully contractile of the paretic vaso- 
motor areas, the latter more directly relaxant of the exactly compen- 
sating spastic areas, both partaking of each of these antagonistic actions. 
In the asthmatic we pick our way cautiously with these two combinations, 
giving the sedative every hour, substituting Burggraeve's whenever the 
heart asks for more power, returning to the Abbott triad whenever possi- 
ble, for reasons evident on consideration of the essential importance of 
free elimination in this malady. One day's skillful handling of these 
two remedies sees our patient exhibiting a degree of improvement not 
credible except to eye-witnesses. The nervous irritability subsides, the 
cough and dyspnea are less severe and frequent, and the smoking — always 
of temporary benefit but in the end injurious to the delicate pulmonary 
structures — is required less frequently, until it may be substituted by 
glonoin. Add to this the most careful clearing of the bowels and other 
eliminants, scrupulous regulation of the diet and digestion, and the case 
soon wears a different aspect. Our vasomotor hypothesis has been con- 
firmed thus far by the application of exact therapeutics on that basis. 

Now then: — Lay aside all other considerations, and directly attack 
the disease as expressed by a local pulmonary, non-inflammatory, non- 
microbic vasomotor relaxation. To contract the paretic area we. give 
strychnine arsenate, beginning with a milligram every four hours, increas- 
ing with close attention to the pulse-tension, The improvement is sure 
and steady — but the doses required may seem perilous. We may reach 
ten milligrams — gr. 1-6 — every four hours, or a grain per diem, or more, 
before we have fully neutralized the paresis and restored normal vascular 
tension, and this enormous dose may be continued for weeks or months, 
lowering it as the need subsides. The arsenic possibly acts here as an 
intestinal antiseptic — its power of promoting fatty degeneration of morbid 
products which renders it so useful in declining inflammations, does not 
seem to be here indicated. Yet, there is too much testimony as to its 



FIBRINOUS BRONCHITIS 303 

value in chorea, and we do not know all about asthma yet. But if 
arsenical symptoms appear we may substitute any other salt of strychnine, 
the nitrate or valerianate being possibly more active as renal stimulants. 
One great side-advantage of the huge doses of strychnine is its powerful 
action on the bowels, increasing sensibility and peristalsis and thus pre- 
venting the retention of feces, and autotoxomia. But it is not the ideal 
remedy, for by its use we are acting on every function and every organ 
in the body when we only need to stimulate the pulmonary vasomotors. 
Give us a remedy that will contract the vessels of the pulmonary circula- 
tion without affecting the greater circulation. Can we find this in the 
persalts of iron? Ergot and adrenalin act only on the larger circulation, 
not on the lesser. Hydrastinine and stypticin act selectively on the uterine 
area. Such selective action seems to indicate similar selection on the part of 
other vasomotor agents and among these there must be one that meets 
our requirements. But it is not to be found among the hemostatics, 
for atropine acts thus in stopping hemoptysis but is useless here. 

If asthma is simply a spasmodic neurosis and nothing more, it is 
difficult to explain how patients can take a grain and more of strychnine 
daily with unquestioned benefit, instead of showing aggravation of the 
spasm with doses below those borne by healthy individuals. But if this 
remedy antagonizes and is antagonized by the disease we can readily 
comprehend why the asthmatic is benefited by doses that would be lethal 
to ordinary persons. 

The results of treatment with therapeutic certainties seem to justify 
us in removing asthma from the category of spasmodic functional neuroses 
to that of the vasomotor pareses. 

FIBRINOUS BRONCHITIS 

This is a rare malady in which fibrinous casts of the bronchi are formed, 
and expelled with difficulty. The casts form molds of the bronchial 
tree. The larger ones are hollow. The epithelium is shed with the cast. 
Anders found the casts identical in structure with ordinary croupal exudates. 

The cause is not known. Streptococci have been found in the casts. 
The malady is more frequent in males, between 20 and 40, in spring, 
sometimes seems epidemic and may be hereditary. Tubercle, pleurisy, 
herpes, impetigo, and pemphigus have been noted as complications. 

The rare acute form begins with rigors, followed by fever, dyspnea 
and severe cough. The expulsion of the casts may be followed by hemor- 
rhage. Free expectoration gives relief. Urgent dyspnea and severe 
dry cough may precede fatal asphyxia. 



3 o4 PULMONARY HYPEREMIA 

In the chronic or recurrent form paroxysms occur at intervals of a 
week to a year, regular or not, the onset resembling that of bronchitis, 
cough severe and paroxysmal, and the white or gray casts appear. They 
consist usually of mucin, some of fibrin. 

Physical examination shows the affected lung to be airless; fremitus, 
expansion and vesicular murmur lessened, percussion normal or hyper- 
resonant, dull if collapsed, the ejection of the casts restoring the normal 
murmur. 

The diagnosis is made by the casts, the history differentiating them 
from croup and diphtheria. Doubtful cases may be settled by a search 
for the Klebs-Lceffler bacillus of diphtheria. 

In the acute form the prognosis is grave. The chronic form is obstinate 
but rarely fatal. 

The treatment is as yet unsettled. Anders obtained good results 
from pilocarpine in one case. Cyanosis calls for emetics. Steam inhala- 
tions and the treatment for bronchitis are advised. If pilocarpine is 
given it should be in doses sufficient to cause free sweating, gr. 1-20, every 
ten to thirty minutes till effect. Potassium bichromate may be tried, gr. 
1-30 every half-hour; or calx iodata, gr. 1-3 every five minutes. 

Dr. S. R. Cates, of Abilene, Texas, after suffering for years with recur- 
rent attacks of fibrinous bronchitis obtained relief and eventual cure from 
the use of hyoscyamine, beginning with the first evidences of an attack 
and keeping himself slightly under the influence of this agent until the 
malady had subsided. 

IV. DISEASES OF THE LUNGS 

PULMONARY HYPEREMIA . 

Collateral hyperemia exists in the unaffected lobes during pneumonia. 
The blood-vessels of the lungs are acutely congested, the epithelium swollen 
and granular. It is the first stage of pulmonary inflammation and may 
be excited by the inhalation of hot air, irritant gases, violent exercise or 
emotion, or the excessive ingestion of liquids, especially alcohol. 

There is a sense of oppression, of lack of air, with a cough, frothy 
bloody sputa and soreness in the chest. Examination shows both lungs 
usually affected, with increased tactile fremitus, some decrease in the 
clearness of percussion resonance, diminished vesicular respiration, some 
bronchial breathing, and moist rales varying with the quantity and con- 
sistence of the fluid present. Respiration is markedly increased in 
rapidity, and there is apt to be some fever, the pulse corresponding. 



PULMONARY CONGESTION 305 

The prognosis is rendered grave by the supervention of pulmonary 
edema. 

The patient is put to bed, the bowels emptied, free perspiration induced 
by pilocarpine, gr. 1-30 every five minutes till full action is manifested, 
and the pulse brought down to 60 by veratrine and amorphous aconitine, 
gr. 1-134 each, with digitalin gr. 1-67 to contract the dilated pulmonary 
vessels, given together every quarter to one hour according to the urgency 
of the case. If the patient is weakly strychnine arsenate in like doses 
should be substituted for veratrine. Meanwhile the irritating, racking 
cough may be checked by codeine and emetine, gr. 1-67 to 1-20 each, 
every half to one hour. If the volume of the blood is reduced by the 
purge and sudorific, and the patient is not permitted to restore the con- 
gestion by the free use of beverages, it will not be necessary to bleed, 
locally or generally. But if edema of the lung is imminent — bleed — 
bleed — BLEED! Nothing else will act as quickly to save life. The 
fear our fathers felt in regard to loss of a little blood was preposterous. 

Arterial tension may require a few doses of glonoin at first, to let in 
I he veratrine more speedily, and let out the blood from the hyperemic area. 

Bleeding may also be required in passive congestion from heart dis- 
eases. The posture should be frequently changed to avoid hypostatic 
congestion. 

PULMONARY CONGESTION 

Passive congestion occurs mechanically as a result of mitral or aortic 
disease, obstructing the outflow of blood from the pulmonary capillaries. 
Compensatory hypertrophy of the right ventricle sustains the aortic circu- 
lation but increases the pulmonary congestion. Some cerebral maladies 
give rise to this condition, which may also be caused by the pressure of 
tumors upon the pulmonary veins. 

The blood-vessels of the lungs are distended, the lungs swollen and 
engorged, the connective tissue hyperplastic in old cases, the air-cells 
compressed and oxygenation correspondingly diminished. The process 
begins at the base of the lungs. 

Dyspnea is pretty constant, a sense of stuffiness, with a disposition to 
take long breaths occasionally. This is worse after meals, as the bulk 
of the blood is then increased. Bronchial catarrh develops, but without 
this the engorgement causes constant irritative cough with serous or 
bloody sputa. The lips are stained as if the patient had been eating 
mulberries. Shortness of breath increases with exertion. 

The diagnosis is unmistakable when cough, dyspnea and hemoptysis 
with deficient oxygenation coincide with valvular heart-disease. 



3 o6 PULMONARY EDEMA 

The term hypostatic congestion is used to designate a condition, most 
common in typhoid states, when the lower portions of the lungs become 
water-soaked, or dropsical. The general vitality is low, the vascular 
tension so reduced that the blood-serum oozes through the vessel-walls 
and collects in the most dependent parts. When the position is changed 
the serum slowly shifts, collecting in what has become the lowest part. 
The air-cells and parenchyma become alike overflowed with serum. 
This is sometimes seen in aged and very feeble people, especially when 
in the last stages of exhausting disease. 

The symptoms may be unnoticeable — unusual weakness, somnolence, 
pulse weak, respiration a little hurried, the mouth open and accessory 
respiratory apparatus brought in use, and deepening cyanosis. Exam- 
ination shows the lungs dull in the dependent parts, serous rales, loud or 
fine bronchial breathing, increased fremitus, the signs shifting when the 
patient's position has been altered for a few hours. 

In both forms of passive congestion the prognosis is that of the pri- 
mary affection. 

Treatment: — In mechanical congestion the treatment is that of the 
causal malady — and in fine this means the reduction of the heart's work 
to the lowest possible limit by the imperative restriction of fluids, so as 
to reduce the bulk of the blood. Richardson sought to relieve the dys- 
pnea and aerate the blood by the use of hydrogen dioxide internally, 
but this could be better done by disengaging in the air of the patient's 
room an extra quantity of oxygen. 

Those liable to hypostatic congestion should be changed about every 
few hours, the heart and arterial tone sustained by strychnine in full 
doses, with berberine, gr. 1-6 every hour to increase capillary tonicity. 
Apocynin in the same dose aids in carrying off the surplus water. Feed 
richly, keep the blood circulating by massage, with stimulating lin- 
ments. Be wary about allowing the patient to lie half-asleep for long 
periods. Sanguinarine in small and repeated doses, gr. 1-67 to 1-20 
every two to four hours, stimulates the vitality of the pulmonary tissues 
and is consequently of special value in this condition. 

PULMONARY EDEMA 

In many morbid conditions blood-serum is effused into the air-cells 
and pulmonary tissues. It forms a zone around pneumonic, purulent, 
apoplectic and tubercular masses. It is an incident in the history of ne- 
phritis, anemia, apoplexy, acute septic fevers and many cardiac maladies. 
In pneumonia collateral hyperemia and edema of the lobes not pneu- 



HEMOPTYSIS 307 

monic form a serious element of danger. In true croup edema is the 
cause of death. The occurrence of edema is favored by any agent that 
causes abnormal fluidity of the blood, overfilling of the pulmonary capil- 
laries, increase or decrease of the tension of the pulmonary blood-ves- 
sels, or innutrition of their walls. 

Dyspnea is the first symptom, and is severe in proportion to the ex- 
tent of the malady. Cough, frothy, sero-sanguineous expectorat on, 
cyanosis with sluggishness, somnolence and finally death by carbonic 
acid poisoning, are the steps in the general pulmonary edema. The 
pulse is weak and rapid, skin cool and livid. The degree of fever depends 
on the causal malady. The percussion note is dull if the edema is marked; 
auscultation discloses moist rales of varying degree, beginning in the 
finest bronchi and becoming coarser as the serum invades larger ones, 
while the vesicular sound is weak or absent. 

The condition is diagnosed from the history, incomplete dullness 
beginning in dependent parts, the progressively larger moist rales, 
frothy, bloody sputa, absence of fever and supervention of cyanosis if 
extensive. In hydrothorax the level of the dullness changes at once with 
change of posture, and there are no rales. Bronchopneumonia begins 
with fever, sticky gray sputa, and the dullness is marked, limited and 
stationary. 

The prognosis depends on the primary disease. Collateral edema is 
a condition of imminent danger. In croup it is a herald of death. 

TreBtment: — Treat the primary malady. Change the patient's 
posture frequently to avoid hypostasis. Bleed for collateral edema 
in pneumonia. Intubate to prevent edema in croup. Feed up, stimu- 
late, and neglect not the blood pressure. Dry cups over the chest are 
useful. Drain the bowels by exosmotic enemas — cold saturated salt 
solution . Give full doses of strychnine to contract relaxed vessels, especially 
in children. 

HEMOPTYSIS 

Pulmonary blood comes usually from the bronchi — rarely in advanced 
phthisis it is from eroded vessels. At the post-mortem we find 
the latter, or ruptured capillaries, swollen mucosa, or a ruptured aneur- 
ism; the affected lung-tissue pale. 

The causes of hemoptysis may be pulmonary hyperemia or congestion 
from any cause (heart disease, pneumonia, inhalation of hot air, 
violent exercise, etc.), infarction pneumonia, tubercle, ulcer of larynx, 
trachea or bronchi, fibrinous bronchitis, cancer and gangrene. Blood 



3 o8 HEMOPTYSIS 

may come from the nose or from other sources, enter the larynx during 
sleep and be coughed up to frighten the patient and mislead the 
doctor. 

A free hemorrhage may first attract attention to a localized deposit 
of miliary tubercle. Much more frequently children who bleed at the 
nose during early life, after reaching puberty have bronchial hemor- 
rhages instead. The effused blood decomposing in the bronchi, excites 
inflammation there, and this may form a suitable nidus for the tubercle 
bacillus. Too many young people have repeated bronchial hemorrhages, 
and yet live to old age without becoming phthisical, to permit of the gloomy 
prognosis of Laennec in similar cases. 

Rarely hemoptysis represents a vicarious menstruation. Purpura 
hemorrhagica, scurvy, ptyalism, anemia, hemophilia, yellow fever and 
malignant malarial fever, may cause hemoptysis. Clarke found re:ur- 
rent hemorrhages in aged persons from gouty endarteritis. 

Symptoms: — In bronchial hemorrhages the patient feels a warm 
salty taste and blood wells up into his mouth, the quantity varying from 
an ounce to a pint. This is generally preceded, perhaps for days, by a 
sense of stuffiness in the chest, with pain or tenderness in the second right 
intercostal space, near the sternum. The patient is frightened, the 
pulse excited, full and rapid, perhaps tumultuous. Each new gulp of 
blood adds to the terror. During the day a second hemorrhage usually 
occurs, and if this is foretold by the doctor, with the assurance of its 
harmlessness, faith and composure follow. Otherwise another attendant 
is usually summoned. Blood is brought up for a few days, while the pa- 
tient shows by fever the degree of damage excited by the dead blood 
in the fragile lung-tissues. If oppression has preceded, a feeling of 
relief and sense of well-being follows the hemorrhage. Rarely is the loss 
of blood sufficient to induce syncope and collapse. 

When tuberculosis is advancing rapidly a large vessel may be 
eroded, in which case the succeeding hemorrhage is apt to be fatal. 
The blood in the above cases is arterial and frothy, not clotted. Bub- 
bling rales may be heard on auscultation. 

Similar hemorrhages may occur in passive congestions from obstruct- 
ive heart-disease, etc., and spitting of blood or bloody sputa is common 
in any destructive pulmonary affection. 

Small hemoptyses precede for weeks the rupture of thoracic aneurism, 
the latter causing sudden death. 

Gouty hemoptysis occurs after 50, most commonly when bronchitis 
is present. Small hemorrhages occur in emphysema also, probably 
from ulcer. 



HEMOPTYSIS 309 

Small hemoptyses occur in weak, hysterical women; others follow 
thoracic injuries, strains and violent emotions. Persons predisposed to 
tuberculosis are apt to have hemorrhages if they go to the seashore, and 
almost any one may suffer similarly on ascending to elevated regions 
or in balloons. 

The diagnosis of pulmonary hemorrhage is made by ascertaining 
that the blood is coughed up, frothy, bright-red, the nose, mouth and 
throat showing no source of bleeding, the lungs revealing it. 

The prognosis is good as to life. Very rarely does any one die from 
pulmonary hemorrhage except from erosion of an artery or bursting of 
an aneurism. But any discharge of blood from the lung demands the 
most thorough search for evidence of tuberculosis. If not found, if the 
week following shows little fever and the sputa are free from pathogenic 
microbes, the hemorrhage is still evidence of a fragility of tissue demand- 
ing instant attention. The immediate effect of a hemorrhage on the 
course of an acknowledged tubercular malady is beneficial. Simple 
blood-spitting is rather diagnostic than prognostic. 

Tre3tment: — Place the patient at ease, the head somewhat elevated, 
with cold to the chest. Reassure him as to immediate danger, announce 
the return of another hemorrhage later in the day, administer a full dose 
of atropine, gr. 1-67, turn the people out of the room and order the patient 
to be kept cool and quiet. Forbid the patient's talking. If the sense 
of oppression is still present, apply a leech or cup over the second right 
intercostal space, close to the sternum, and subdue the bounding heart 
with aconitine or veratrine, "dose enough" to do the work. Keep the 
patient very quiet as long as any fever is present, feeding on small doses 
of ice-cream and the most concentrated nutriment, predigested if neces- 
sary. Forbid all fluid but what is absolutely unavoidable. For thirst 
allow pellets of ice, or chewing-gum. Examine the chest thoroughly. 
If a tubercular lesion is found treat that disease. Heart-disease, aneurism, 
etc., require their own treatment. In case of aneurism ice to the chest 
may delay death for a paltry period. In vicarious menstruation antici- 
pate the next monthly epoch by active emmenagogs, and repeat this 
each month till it is no longer necessary. 

If the most vigorous search fails to disclose evidence of pulmonary 
tuberculosis, while the history and aspect of the patient show the case 
to be one of tissue-fragility, predisposition to phthisis, the question is 
of prophylaxis. If a youth of proper age, a long sea-voyage, a year or 
more, is advisable. Calcium lactophosphate should be given, gr. 7 1-2 
daily for a year; the bowels regulated, the digestion scientifically built 
up, the body invigorated and toughened by suitable exercise, cold baths, 



310 PULMONARY APOPLEXY 

salt rubs, pneumonic gymnastics, cod-liver oil inunctions, the climate 
suitable to the case, etc. 

Whenever there is the warning sense of oppression the heart should 
be sedated by vera trine and a dry cup placed over the danger-point. If 
the symptoms recur quickly, introduce a seton through the skin wherever 
pain or fullness is felt. 

The diet must be carefully suited to the case. A flood of hot soup or 
alcoholic beverages may bring on hemorrhage. All excesses that impair 
the vitality must be prevented. An out-door life, in an equable climate, 
as high up the mountains as the patient can comfortably endure, is the 
ideal. While emphatic in our view that these cases are not necessarily 
tuberculous, we grant freely their liability to become so, and the regime 
enjoined is that employed to prevent the development of tuberculosis. 
This point is of the utmost importance, for many a doctor and patient, 
convinced by the hemorrhage of the preexistence of tuberculosis, have 
allowed the cases to go by default that might otherwise have lived to a 
healthy old age. 

We have dropped all the old hemostatics for atropine. By forcibly 
dilating the cutaneous capillaries this drug attracts the blood to the 
surface and reduces the congestion of the internal organs. If the blood 
is safely held at the periphery it cannot at the same time be escaping from 
engorged vessels in the lungs. Besides this, atropine sedates the pneumo- 
gastric and checks the cough. While it is in a sense antagonistic to the 
arterial sedatives recommended, aconitine and veratrine, actual trial 
has confirmed the apparently paradoxic claim that such antagonists will 
act in the same body at the same time, each exerting its special force 
where needed. It is well to accompany the atropine with a few doses 
ofglonoin, gr. 1-250 every ten minutes, to relax arterial tension, open the 
vessels for speedier action of the other drugs, combat the tendency to syn- 
cope and attract the blood to the head, where it is held by the slower 
but more persistent atropine. The only effect of astringent sprays is 
upon the mentality of the patient, for by no possibility can they reach 
the bleeding orifices. 

The persalts of iron tend to restrain nemorrnages in the pulmonary 
tract; protosalts to induce them. 

PULMONARY APOPLEXY 

Sometimes there is an escape of blood into the lung-tissues, similar 
to a cerebral apoplexy. It occurs from rupture of an adherent aneurism, 
from wounds, and in some cerebral and septic maladies. 



PULMONARY EMBOLISM 311 

There is profuse hemoptysis, great dyspnea, cyanosis, collapse and 
signs of consolidation suddenly following the causal lesion. It ends 
in death at once, or after abscess or gangrene has supervened. 

The treatment is absolute rest, cold locally, and atropine in full doses 
hypodermically, gr. 1-67, at once. 

PULMONARY EMBOLISM 

A pulmonary artery is blocked by an embolus. The lung supplied 
becomes engorged with blood, airless, dark, the pleura covering the base 
of the wedge inflamed, and a zone of edema surrounds it. If the embolus 
consisted of septic matter the part breaks down into an abscess. In 
leucocythemia plugs composed of leucocytic masses form small emboli. 
Vegetations loosening from the valves of the heart sometimes enter the 
lungs. 

Small non-septic emboli may occasion no symptoms; large ones may 
cause speedy death with symptoms of pulmonary apoplexy. The usual 
symptoms are dyspnea, syncope, pleuritic pain, spasms and coma. The 
dyspnea occasions great distress and struggling for breath. Bloody 
expectoration occurs early. If a cardiac murmur ceases, with the sudden 
development of localized pneumonia, hemoptysis, pleuritic pains, pre- 
ceded by convulsions and unconsciousness, the diagnosis is clear. Small 
infarctions may not cause dullness; large ones do, with moist rales, 
increased fremitus and bronchial respiration, with pleuritic friction. 
The pulse is weak and rapid, skin cool, the forces prostrated. Fever 
follows reaction in large infarctions. 

The prognosis depends on the nature of the embolus and the impor- 
tance of the vessel occluded. If abscess or gangrene occurs death quickly 
follows. In case of recovery the affected part shrinks, forming scar- 
tissue, or calcifies. 

The treatment consists of rest, careful feeding to support the strength, 
and anodynes to ease the pain. Atropine may be given for this pur- 
pose, with codeine enough to prevent painful cough, and anodyne applica- 
tions to the skin. 

BRONCHOPNEUMONIA 

In capillary bronchitis we find evidences of inflammation of the smallest 
bronchi and the air-cells. Dark patches are found, surrounded by healthy 
tissue, the one exuding mucopus when cut, the other serum. The large 
bronchi are healthy, the smaller ones contain secretions, the walls thick, 
dilated, the cut surfaces nodular. Large areas may be almost wholly 



312 BRONCHOPNEUMONIA 

consolidated, airless, at first reddish, later gray. Both lungs are affected 
in parts. The bronchial glands are inflamed, the pleura somewhat also, 
the air-cells of other parts of the lungs dilated. The malady begins as 
an inflammation of the cells and bronchioles constituting a lobule, new 
tissue being formed therein, the malady tending to chronicity. The 
exudate consists of serum, mucus, alveolar cells, leucocytes, and a few 
red blood-cells. The leucocytes in the blood multiply, except in fatal 
cases. Concomitants are bronchial catarrh and exudative inflammation 
of the air-cells. 

Etiology. — The malady is most frequent among children, and with 
measles, rickets, scarlatina, whooping-cough and diphtheria. Excitants 
are exposure to cold and wet, bad air, bad hygiene and digestive derange- 
ments. A form of bronchopneumonia also prevails among the aged, 
enfeebled by disease. It is most prevalent in cold, wet seasons, occurs 
with influenza, typhoid fever, erysipelas and smallpox. The inhalation 
of irritants seems to excite attacks, as does the tubercle bacillus. 

Streptococci are frequently found in the sputa, also pneumococci, 
staphylococci aurei, influenza bacilli and numerous other microorganisms. 

The malady following acute infectious fevers is now believed to be 
usually tubercular. 

Symptoms: — Primary forms, occurring usually in adults, present symp- 
toms of severe acute bronchitis. In weak patients the onset may be 
gradual. The sputa is scanty and sticky, gray or blood stained, fever 
ioi° to 104 F.; irregular but higher in evenings, ending by lysis in two 
to four weeks. 

More common is the secondary form, the early symptoms masked by 
the previous affection. The malady extends down from the larger bronchi 
and is marked by a sudden rapidity of respiration, with higher fever, 
harassing cough and expectoration. The pulse grows rapid, feeble and 
irregular. 

Capillary bronchitis is indicated by subcrepitant rales, followed by 
some dullness, not limited to single lobes, but more marked in the back 
between the shoulder-blades. Dyspnea and duskiness of the lips are 
noted, the hurry of respiration is extreme, the eyes and finger-nails are 
blue. The respirations are shallow. The fremitus is increased, breath- 
ing is bronchial, yet the consolidation is rarely as complete as in lobar 
pneumonia. 

Unless death comes sooner the attacks last from one to several weeks. 

In the cerebral form there are at the outset restlessness, convul- 
sions and delirium or stupor, early high fever, followed by prostration. 
Some days later the pulmonary symptoms replace the cerebral. There 



BRONCHOPNEUMONIA 313 

may be gastrointestinal disorders in any form. Some cases run on for 
many weeks, the consolidation remaining. In fact, the affected areas 
may remain permanently solidified. The fever may be irregular. 
Other cases develop like lobar pneumonia, with chills, high fever, pain 
in head, chest and back, marked prostration following with the usual 
symptoms in aggravated form. In another group the onset is insidious 
the course chronic, hectic fever and night-sweats following. 

The diagnosis between this affection and lobar pneumonia is not as 
a rule difficult. Lobar pneumonia begins abruptly with a chill, there 
is crepitation followed by dullness limited to one or more lobes, rusty 
sputa, typical fever, ending in crisis; it is often unilateral, without 
bronchial catarrh or severe dyspnea; the pneumococcus is present. 
Bronchopneumonia develops usually out of one of the maladies named, 
begins gradually with bronchitis preceding, the dullness is bilateral, not 
absolute, not limited to the lobes, but most marked between the scapulae; 
subcrepitant rales, respiration hurried, great dyspnea and cyanosis, fever 
irregular ending by lysis, course prolonged; sputa glairy, in adults blood- 
spotted; often ends in tuberculosis; streptococci and other microorgan- 
isms than pneumococcus are present. 

Pleurisy has dullness at the base of one or both lungs. In tubercu- 
losis the bacillus is present. 

The prognosis is grave in proportion to the weakness of the patient 
and the extent of the disease. The mortality varies from 25 to 50 
per cent. 

TreBtment: — Attacks may be prevented by guarding against colds 
during and after the affections above named. The mouth should be 
regularly cleansed with antiseptic lotions during all septic fevers. 

Perhaps no other remedy counts for so much in this malady as the 
constant inhalation of steam. The chest should be painted with tinc- 
ture of iodine and enveloped in a cotton-jacket. The more acute cases 
require veratrine, aconitine and digitalin for the fever, changing the 
veratrine to strychnine arsenate at the first indication of debility. The 
adult dose is gr. 1-134 of each, except of digitalin, which is gr. 1-67 every 
half, one or two hours, according to the pulse and the fever. For chil- 
dren under ten Shaffer's rule is applicable: Put in a glass one adult dose 
for each year of the child's age, add one more, and 24 teaspoonfuls of 
water; then give a teaspoonful as often as required. Thus, a child one 
year old would take two-twenty-fourths of the adult dose, a child 8 years 
old nine twenty-fourths. 

The bowels must be emptied and kept soluble, the strength supported 
by judicious feeding, the alimentary canal kept aseptic. 



3 i4 CHRONIC PNEUMONIA 

Will any agent favor resolution and fluidify the exudate? Calomel, 
ipecac, ammonium chloride, apomorphine, lobelia, potassium bichro- 
mate, each has been faithfully tried without giving convincing proof of 
its utility. One case responded promptly to ammonium iodide, another 
to strychnine in desperate doses; and we would to-day prefer the latter 
to any other remedy. Opiates in all forms are deadly. The cough 
will be better relieved by steam. The inhalation of oxygen may tide 
over a case. Injections of normal salt solution may be of value. 

An emetic may be required occasionally to free the lungs of secretions. 
If there is difficulty in expelling it, the remedy is sanguinarine. 

CHRONIC PNEUMONIA 

Cirrhosis or fibrosis of the lungs occurs in two forms, local and diffuse. 
It is unilateral. The history is that of cirrhosis elsewhere — there is 
hyperplasia of the connective tissue, which later contracts, both pro- 
cesses being at the expense of the air-cells and glandular elements, whose 
space is seized first and which are choked out by the contraction. The 
affected part of the lung is converted into a fibrous, scar-like mass, oc- 
cupying less space than when healthy. The vacated space may be filled 
up by retraction of the intercostal and clavicular spaces, emphysema, 
bronchiectases, and the heart may even be drawn over towards the 
affected region. Adhesions may form. Tuberculosis may follow. 

The affection is secondary to various inflammations, tubercle, syphilis, 
hydatids, etc. The diffuse form follows acute pneumonia with missed 
crisis, influenzal pneumonia, pleurisy, atelectasis and especially broncho- 
pneumonia. 

The process begins in the submucous layers and extends into the 
parenchyma. It may arise primarily or from the inhalation of irritants. 

The symptoms are cough, expectoration, early dyspnea, worse on 
ascending heights, oppression, pain if the pleura is involved. There 
is no fever. Other symptoms are due to the accompanying conditions. 

The chest- wall is shrunken, or swollen with emphysema; the side 
may be distorted to bring the ribs closer, the spine curving, the heart 
displaced. The fremitus is increased, percussion dull, breathing bron- 
chial, with signs of bronchiectasis if present. Rales depend on the pres- 
ence of fluid. 

The malady is slowly progressive. Acute pneumonia may occur. 

There is no known curative treatment. The efforts of the physician 
should be directed to securing the patient's comfort, treating compli- 
cations and prolonging life. 



ATELECTASIS 315 

Thiosinamin is said to possess the power of destroying scars, and 
even of causing the absorption of urethral strictures. It may check 
pulmonary fibrosis. The dose is gr. 7 1-2 in fifteen per cent alcoholic 
solution, injected into the gluteal tissues. The severe pain is alleviated 
by drawing the solution into the syringe and then a few drops of four 
per cent cocaine solution, which is thus first injected. Singularly, 
the anesthetic action of the cocaine is manifested immediately. The 
dose should not be repeated more than once a week. Europhen with fluid 
petrolatum, one part to eight, should be sprayed into the lungs daily, 
as this agent also seems to have local absorptive powers that may be of 
value here. Thiosinamin is now advised by the mouth, a grain 3 to 5 
times a day for months. 

ATELECTASIS 

The term atelectasis denotes a permanent collapse of the air-cells 
forming a lobule. The affected lobule is solid, airless, dark, the bronchi 
occluded by exudate, but inflatable by the blow-pipe. The capillaries 
are distended. 

Etiology: This occurs in new-born infants from imperfect distention 
of the lungs. In older children it is caused by stoppage of the bronchial 
lumen by exudates, the air being absorbed or expired. Compression 
of the lungs causes it, even that of flatulence. It also results from some 
cerebral diseases, pneumogastric paresis, and paralysis of the chest- 
walls. Distortions of the thoracic cage may be attended by atelectasis. 

The symptoms occur during the primary affection, which is most 
frequently bronchopneumonia. Respiration is rapid and shallow, with 
dyspnea in older children, lividity and cold skin and extremities in new- 
born babes. The pulse is feeble and rapid, the cry weak, and carbonic 
acid poisoning ensues, insidiously in the case of infants. 

If extensive, over the posterior lower lobes, this part of the thorax 
retracts during inspiration; the percussion note is dull, unless masked 
by emphysema; with vesicular murmur, weak bronchial breathing, sub- 
crepitant rales. 

The diagnosis from lobar pneumonia is made by the location of the 
dullness, in the posterior part of both lungs, disseminated through all 
parts but most marked between the scapulae and in the lower lobes; by 
the dyspnea and cyanosis and the absence of the signs of true pneu- 
monia. 

If the process is extensive it is apt to be permanent, the function of 
the affected tissue being lost. In infants it is a dangerous affection. 



316 EMPHYSEMA 

With whooping-cough bronchopneumonia or pleurisy, it is often fatal. 
Emphysema simply masks the malady and adds to the injury. 

The treatment is that of the causative malady. Inflating the lung 
forcibly should be practised to prevent or relieve the collapse; the posi- 
tion should be changed regularly. Infants must be made to cry 
vigorously. An effective measure is placing the child in a warm bath 
and squirting cold water forcibly against the chest. Sanguinarine is 
useful as a stimulant to the cough; the dose being gr. 1-134 every half- 
hour to a child two years old. 

EMPHYSEMA 

Interlobular emphysema is due to rupture of the air-cells, the air 
escaping into the connective tissue. It may be due to wounds, violent 
coughing or sneezing and other strains. The most common locality is 
the clavicular region, which may puff up with escaped air. This may 
penetrate the pleura, or the subdermal tissue over the entire body. 

Vesicular emphysema is a simple dilation of the air-cells without 
rupture. It is termed compensatory when it aids in filling up the vac- 
uum caused by loss of part of the thoracic contents. It is only compen- 
satory as to volume, not as to function, as the enlarged cell aerates but 
little more blood than the small, and not nearly as much as the group 
of cells normally occupying the same space. 

Hypertrophic emphysema is due to permanent dilatation of the air- 
cells, by overstretching. The lungs do not collapse when the pleura 
is opened. Presumably there is in these cases a congenital deficiency 
of the elastic tissue. 

The thorax becomes barrel-like, the lung-tissue anemic, pitting on 
pressure. The cells are notably large, of various sizes, pleura pale, 
showing patches devoid of pigment (Virchow's albinism). The septa 
are thinned and broken, the cells coalescing, the elastic fibers broken or 
atrophied, the capillaries disappear, the epithelium becomes fatty. The 
muscular fibers may become hypertrophied. The larger blood-vessels 
are enlarged. Bronchial catarrh usually coexists, with cirrhosis and 
bronchiectasis. The diaphragm is depressed, the heart lowered, its 
cavities dilated or hypertrophied, the pulmonary arteries enlarged 
and atheromatous. Other viscera show the effects of prolonged venous 
engorgement. 

Etiology: — Emphysema in the upper lobes develops in whooping- 
cough, bronchitis, etc., from the violent strain of coughing while the 
glottis is closed. Asthma, playing wind-instruments, blacksmithing, 



ENPHYSEMA 317 

and other occupations involving similar pulmonary strain, cause em- 
physema. The loss of elasticity and atrophy of the tissues in old age 
gives rise to a harmless emphysema, and if contracted in childhood it 
reappears in old age. 

Symptoms: — Emphysema being not so much a distinct disease as a 
process entering into the clinical history of various maladies, its symp- 
toms are those of the latter. It slowly develops from occupations, but 
occurs suddenly as an accident from unusual strains. It causes dyspnea, 
dry cough, perhaps cyanosis, the breathing-power lessens on exertion 
or after full meals, becoming worse as the malady increases. Expiration 
is laborious and prolonged. In advanced cases the cyanosis becomes 
extreme. Expectoration depends on the coexistence of catarrh, which 
is a frequent concomitant, acute attacks developing a cyanosis not 
usual to bronchitis alone. There is no fever, the pulse is normal or weak, 
the temperature subnormal. The patient becomes thin, weak, stooping, 
cachectic. The right ventricle hypertrophies to force the blood through 
the fewer capillaries. 

Besides the barrel chest, the winged scapulae are characteristic, and a 
belt of dilated venules may be seen around the lower border of the ribs 
and cartilages. Hyperresonance is present, the vesicular sound is weak, 
expiration prolonged, and the cardiac dullness is obscured by overlap- 
ping lung. The unaffected parts give a harsh vesicular murmur. Bron- 
chitic rales are usually present, with those due to any other complication. 
Dry crumpling sounds may be heard, or Laennec's rale, resembling 
the subcrepitant. 

The diagnosis is made from the history, occupation, dyspnea, cyanosis, 
barrel chest and other signs. Pneumothorax develops suddenly, uni- 
laterally, with violent dyspnea, clear tympanic note, amphoric breath- 
ing, soon followed by the splashing of liquid. 

Acute emphysema is curable, the chronic form permanent and usually 
progressive, though the symptoms may be checked or show improvement 
under treatment. Patients are carried off by intercurrent disease, dropsy, 
hemoptysis, or sudden dilation and failure of the right ventircle. 

TreBtment: — Remove the cause. Treat the bronchit's. Potassium 
iodide has long been recognized as exerting a remarkably beneficial in- 
fluence over emphysema. The dose is gr. 15, thrice daily. The causal 
occupation or habits must be given up. Cough must be held in check, 
colds prevented, asthma relieved, the bowels kept soluble, flatulence 
guarded against, and the nutrition sedulously maintained. The heart 
must receive careful attention. Sudden and urgent dyspnea may re- 
quire venesection. Mechanical compression of the chest, by hand or 



318 PULMONARY GANGRENE 

apparatus, has proved of service. Inhaling compressed air and exhaling 
into a partial vacuum is a promising method. When cyanosis becomes 
distressing, arrangements should be made for oxygen inhalation at the 
patient's convenience. Patients with emphysema are thought to do well 
in Minnesota, even in winter. 

PULMONARY GANGRENE 

Diffuse gangrene in the lungs is rarely met in pneumonia. As a 
consequence of occlusion of a large artery a whole lobe or lung may be 
affected, the tissues becoming black, soft and putrid. Emboli cause 
circumscribed gangrene, more frequent in the right lung, and in the lower 
lobe close to the pleura. The tissues turn greenish brown, softening 
at the center into a cavity. A zone of inflamed tissue surrounds it and 
the discharge inflames the air-passages it reaches. The affection spreads 
by direct extension to lung and pleura, and secondary embolism may 
occur in the brain or elsewhere. The gangrenous patch may become 
encysted and the patient recover with a cavity. 

The causes are putrefactive bacteria, staphylococci, lodging on pul- 
monary tissues whose vitality has been reduced too low for successful 
resistance. Gangrene occurs , in the course of pneumonia, infarctions, 
bronchiectatic and other cavities, traumatisms, cancer, compression 
and embolism. Foreign bodies, food, etc., entering the lung are specially 
liable to cause gangrene. It occurs sometimes in convalescents and in 
diabetics. 

The symptoms are cough, profuse intensely fetid sputa, separable 
on standing into three layers, an upper frothy gray-yellow, a middle 
clear serous, a low greenish-brown sediment containing shreds of lung- 
tissue, blood, bacteria, fat-crystals, mucopus, amorphous matter and 
leptothrix. Ciliated monads have been found. If the gangrene does 
not discharge by the bronchi neither fetor nor sputa may be present. 
Fatal hemorrhage may result from erosion of an artery. The physical 
signs are those of consolidation, with a cavity after evacuation; the usual 
rales from the bronchi or inflamed layer.) There is fever of irregular 
type with great prostration and rapid wasting, death advancing rapidly. 

The diagnosis is made by the unequaled fetor of the breath, peculiar 
sputa and rapid sinking. 

The prognosis is grave in proportion to the extent and rapidity of 
the gangrenous process. 

Treaf/ne/lf: — Spray or atomize with phenol lotions and volatile oils, 
as strong as can be borne. Give the latter internally in full doses, with 



PULMONARY ABSCESS 319 

sanguinarine, strychnine and the richest possible diet. Just as soon 
as there is an opening for surgical intervention it should be embraced. 

PULMONARY ABSCESS 

Abscess of the lung may be diffuse or circumscribed, of any size up 
to an entire lobe. If the pleura is reached there may be fibrinous 
adhesions, emphysema or pyopneumothorax. Streptococci, pneumococci, 
Friedlaender's bacilli and other organisms have been found. Abscess 
has followed pulmonary inflammations (usually diffuse), perforations, 
embolisms, pyemia, emphysema, and usually attends chronic tuberculosis. 

The sputa contain pus, and are fetid, but less so than gangrene, 
containing many elastic fibers. The cavity can be located if large 
enough. The fever is of the hectic type, with chills, perhaps daily. 
Leucocytosis is marked. 

Pyemic abscess presents little hope. If the causal affection is 
amenable to treatment the abscess is a harmful event, not necessarily fatal. 

TreBtment: — Keep up the patient's strength with rich food, 
strychnine arsenate gr. 1-30, iron and quinine arsenates each gr. 1-6, every 
four, three or two hours; with all the resources of the reconstructive 
regime. Put a stop to the suppurative process by speedily saturat- 
ing the body with calcium sulphide, one grain seven times or more 
each day, till the breath smells of the drug. Spray with volatile 
oils, thymol, eucalyptol and camphor-menthol, gr. 15 each in an ounce of 
fluid petrolatum, very often. Aspirate or drain large abscesses as 
early as practicable. 

Give nuclein solution, ten minims every three hours, and in great 
depression add zinc phosphide, gr. 1-6 four times a day. The potency 
of these remedies is commensurate with the gravity of the situation. 

PNEUMONOKONIOSIS 

Men who work in coal-mines inhale the carbon as dust; it is 
deposited in the lungs faster than the mucous cells can dispose of it, 
penetrates the perivascular lymph-spaces, is enveloped in the leu- 
cocytes, and conveyed to the lymph-nodules, interlobar spaces and 
lymphatic glands. Catarrh with emphysema may occur. More often 
interstitial inflammation is set up, resulting in fibrosis. Some of the 
indurated areas may soften, and then ulcerate if air is admitted. This 
ends in tuberculosis. All city-dwellers have some degree of this 
anthracosis, but not to an injurious extent. 



3 2o PULMONARY CANCER 

. Chalicosis, stone-cutter's consumption, occasions a similar affection. 
Tool-grinders suffer still more acutely. Siderosis applies to the malady 
as exhibited by dyers. Grain-shovelers, cigar-makers, cotton-spinners, 
millers, and all workers in dust-laden atmospheres suffer similar 
maladies, the symptoms varying with the nature of the dust inhaled. 
Polishers in watch-case factories, inhaling rouge, seem also specially 
liable to epilepsy. 

The symptoms are those of bronchitis of varying grades, generally 
chronic. Emphysema follows. The sputa contain the dust, muco- 
pus, and in due time the tubercle bacillus. The microscopic examination 
and the history suffice for the diagnosis. The prognosis depends on 
the stage the malady has reached and the ability of the sufferer to 
secure healthier occupation. 

Treatment! — One of the finest object-lessons is secured by covering 
the nose and mouth with a respirator of wet flannel, and breathing 
through it the air of the workshop. In a short time the respirator 
is so clogged that it must be renewed, or washed out and replaced. 
Its use prevents the malady. Nowadays many shops are properly 
ventilated and free from this evil. In others the owners advise the 
use of respirators, but find it difficult to induce work-people to use 
them. When the disease has begun the patient must * leave the 
dusty shop for a fresh-air occupation. The treatment is that of 
bronchitis, etc. 

PULMONARY CANCER 

All forms of cancer occur in the lungs, usually secondarily to its 
development elsewhere, the infection (?) being carried by the blood 
or lymph-vessels, or by extension directly. The causes are those of 
cancer in general. 

The symptoms are pain (especially when the pleura is involved), 
inflammation excited by the growth, dyspnea and cyanosis. If the 
growth compresses the heart or great vessels the circulation is disturbed; 
pressure on the esophagus causes dysphagia, on the recurrent laryngeal 
nerve hoarseness or aphonia, on the trachea dyspnea, etc. The sputa 
contain blood, and may resemble currant- jelly, or be grass-green or 
putrid. The tumor causes dullness and loss of vesicular murmur; 
the thorax may be pressed out or perforated, the superficial veins 
engorged, and edema appears in the obstructed area. The cervical 
or axillary glands may be involved. 

The diagnosis is made from the existence of cancer elsewhere, and 
the evidence of a thoracic tumor, steadily increasing, causing irritation 



HYDATIDS 321 

and pressure-symptoms, the cancerous sputa, the lymphatic glands being 
involved. The prognosis is bad. The treatment simply means relief 
of pain — morphine and chloroform ad lib. 

What has been said of carcinoma applies as well to sarcoma, save 
that the course is usually more rapid. Among cobalt-miners there has 
been found a form of pneumonokoniosis attended in some cases with 
the development of slowly growing lymphosarcomas, with secondary 
growths in the lymphatic glands, liver, spleen and pleura. 

HYDATIDS 

Primary pulmonary hydatids are exceedingly rare, secondary ones 
very rare. The symptoms are those of the original development, usually 
in the liver, with pain, cough, dyspnea, sometimes bloody sputa, and 
the physical evidences of the developing tumor. The characteristic 
hooklets may be expectorated. The cysts may discharge through the 
bronchi or the serous sacs, or externally, causing inflammation in their 
path. It is a dangerous affection. 

The treatment is surgical. 

CHRONIC PHTHISIS 

The causes are those of the acute form. The infection is less 
virulent, or the body forces more powerful, and the malady drags along 
for years. 

Pathology: — The upper lobe is usually first affected near the apex, 
the lower lobe next, then the upper lobe of the other lung. The 
left side is primarily affected somewhat more frequently than the 
right. 

The primary lesion is tuberculous infiltration, beginning in the 
air-cells or bronchioles, which are soon obstructed by debris; 
caseation follows, then softening, liquefaction forming cavities, 
increasing by ulceration; or calcification may ensue, or fibrosis. 
Extinct tubercle may be surrounded by zones of compensatory 
emphysema, or of cirrhotic tissue. 

Tubercular nodules in the bronchial mucosa may break down 
and the resulting ulcers become infected by pyogenic bacteria and 
spread. The same process occurs in the cavities formed by soften- 
ing, when open to the air. In slowly progressive cases, or when 
tubercular infection follows thoracic disease causing loss of lung- 
substance, bronchiectasis may occur, and the cavities may increase 



322 CHRONIC PHTHISIS 

by ulceration, their walls breaking down under the influence of septic 
matter collecting in them. Gradually enlarging the cavities communicate, 
the septa breaking down, sometimes forming large compound cavities, in 
which large masses of sputa collect and decompose. The effect of such 
matter coming in contact with the healthy lung and bronchial tissues 
adds much to the distress and increases the area of the disease. 

The walls of freshly formed cavities are soft and necrotic, those 
of older cavities are lined with a pyogenic membrane, later becom- 
ing exfoliative. Bronchiectases may present smooth walls. Large 
cavities may be traversed by fibrous cords formed of obliterated 
arteries. Arteries still pervious are studded with aneurismal dilata- 
tions, often the source of hemorrhages. The most common seat of 
cavities is the upper lobe. Small cavities may become obliterated by 
the contraction of the fibrous capsules. In this capsule tubercle bacilli 
may penetrate, and their destructive work enlarge the cavity, or fibrosis 
may extend into the surrounding zone of lung-tissue, thickening the 
protective wall at the expense of the pulmonary parenchyma. It is to 
this process that the dullness on percussion is mainly due, not to tubercle, 
which only occasions dullness when in large nodules. Hence, dullness 
in chronic phthisis is usually a good prognostic. Disseminated miliary 
tubercles do not cause dullness, and their effects are more rapidly fatal 
than those of isolated nodules, even if large. The miliary tubercle, 
with its zone of fibrosis or caseation and compensating emphysema, 
when multiplied countlessly, disables a large proportion of the pulmonary 
tissue. The process is similar, occurring in many small spots instead 
ot one large one. Miliary tubercles are usually deposited also in the 
pleura, bronchial glands, larynx, and other organs. 

Symptoms: — The affection comes on gradually from a condition of 
debility, in convalescence or exhaustion. There is evident a decline 
in strength, loss of weight, anorexia, inability to digest foods previously 
agreeable, with slight hacking cough of which the patient may not be 
conscious. Some fever becomes apparent towards evening, perhaps 
with bright eyes, flushed cheeks and unusual brilliance in conversation. 
When at last the patient consults the physician, self -prescribed treat- 
ment proving futile, there may be found a few very fine rales, heard at 
the end of forced inspiration, over a limited area of one lung, in the clav- 
icular spaces in front, or more frequently in the space uncovered by 
the angle of the scapula when the shoulders are drawn forward. Only 
a slight local catarrh; but a localized catarrh in the upper lobe of one 
lung is ominous! There is value in the popular saying that a cough 
is dangerous inversely to its strength. 



CHRONIC PHTHISIS 323 

In other cases the attack opens with pleurisy, marked indigestion, 
peritonitis or laryngitis. More acute cases begin like pneumonia, with 
regular periodic chills, or with bronchial hemorrhage. 

The course of the malady is so varied that an analysis of the symp- 
toms will give a better idea of it than an attempt at detailed description. 

Pain may be due to pleurisy, straining of the diaphragm by severe 
coughing, aching preceding hemorrhage, or pleurodynia accompanying 
phthisis but not due to intercostal tuberculosis. Aching between the 
scapula? is of diagnostic value. 

The cough is at first slight, later varies with the course of the disease, 
irritative especially if the larynx is affected or when decomposed secre- 
tions flow into healthy bronchi. Cough on rising, and later on lying 
down, is characteristic. Coming at meals it may cause vomiting. 

There is little or no sputum at first, then it becomes gray and sticky, 
afterwards is yellow or green, as pus forms, bloody when ulceration is 
active. The continuance of gray sputa when a bronchitic discharge 
would have become yellow is significant. The sputa from cavities have 
been described. The sputa mainly consist of mucus from the bronchi, 
and contain tubercle bacilli and other microorganisms, pus, blood, elas- 
tic fibers when lung-tissue is breaking down, fat, food-particles, and 
substances inhaled. 

To examine for tubercle bacilli select a grayish bit, spread evenly 
over a cover-glass previously sterilized by holding in the flame of a spirit 
lamp; dry over the lamp, and fix by passing through the flame, stain 
with carbol fuchsin, decolorize with nitric acid, wash and stain with methy- 
lene blue. Viewed with a 1-12 oil immersion lens and Abbe condenser 
the tubercle bacilli appear as red rods in a blue field. Many and re- 
peated examinations are necessary before one can say there are no tuber- 
cle bacilli in the sputa, for failure to find them on one slide does not prove 
there are none in the whole quantity. In collecting sputa for examin- 
ation let the patient eject that collected in the throat and save what he 
brings up "from the bottom of the lungs," after full deep coughing. 

To find elastic fibers, the sputa should be boiled in a solution of 
caustic soda, one part to thirty-two of water, and allowed to settle in a 
conical beaker-glass. The lowest drop can be taken up by a pipette 
and placed on the slide. Fibers from the air-cells are interlaced, those 
from blood-vessels or bronchi are long and parallel. Some are branch- 
ing. They are relics of broken-down lung-tissue; the cause of the de- 
struction is gathered from the symptoms. 

We have already discussed the relations of bronchial hemorrhages, 
which may indicate the presence of tuberculosis or may be the cause of 



3 2 4 CHRONIC PHTHISIS 

it by preparing a suitable soil through the influence of the decomposed 
blood on the pulmonary tissues. Profuse hemorrhage occurring late 
in the course of phthisis or when ulceration is progressing rapidly, indi- 
cates erosion of an artery. Smaller hemorrhages are not uncommon 
and are usually beneficial, the patient feeling relieved, the fever and cough 
subsiding. Blood-spitting, small quantities of blood in streaks, is very 
common and does not necessarily indicate tuberculosis. Pneumonic 
or stained sputa occur from capillary oozing. Change of residence to 
the sea-shore, or to an elevation 5000 feet or more above the previous 
habitation, is apt to be followed by a hemorrhage. The phthisical pa- 
tient is liable to engorgement of the lungs and consequent hemorrhages, 
from emotion, over-eating or drinking, exposure to cold, and from un- 
known conditions. A sense of vascular fullness, thoracic stuffiness, 
with pain most frequently referred to the second right intercostal space 
near the sternum, and irritative cough, often precede the hemorrhage 
for one or several days. 

Dyspnea is conspicuously slight, considering the degree to which 
the respiratory tissues are inhibited or destroyed. Respiration is accel- 
erated, however, and in proportion to the fever and the tissue-destruc- 
tion. Unusual exertion quickly demonstrates the absence of a pulmonary 
reserve. 

Inspection shows the thorax flat above, intercostal spaces wide, clav- 
icular spaces sunken, lower part of sternum depressed, scapulae wing- 
like, the angle of Louis prominent. The " paralytic" thorax may precede 
or follow the development of phthisis. Emaciation is usual, the skin 
soft, elastic, greasy, sometimes emitting a catarrhal odor. Expansion 
is defective over the diseased area, best ascertained by palpation. Tac- 
tile fremitus is increased early. Forced expansion is less than two and 
one-half inches, unless the patient has trained for this test. 

Dullness on percussion is evident in the clavicular spaces, when the 
lung below is consolidated. This is mainly due to fibrosis. Dullness 
in other parts of the lung may indicate large tubercular nodules or cir- 
cumscribed pleuritic exudations. 

The first note of danger may be a fine crepitation heard at the apex, 
or under the posterior angle of the scapula, confined to a limited area, 
heard at the end of a forced inspiration. Prolonged expiration is an early 
sign, and inspiration broken into " steps. " Sharpened vesicular breath- 
ing is followed by bronchovesicular and this by bronchial. During the 
progress of the malady every form of rale known may be heard, crepitant, 
subcrepitant, mucous, submucous, sibilant, sonorous, rhonchus, ego- 
phony, pectoriloquy, etc., as well as every form of pleuritic sound. 



CHRONIC PHTHISIS 325 

Cavities cause marked retraction and loss of motion, increased tactile 
fremitus if empty, less sound-conduction if full, dullness on percussion 
if full of secretion, tympany if large and full of air. The note is louder 
and higher pitched if the mouth is wide open (Wintrich's sign). The 
tympanitic note may change pitch with change of posture (Gerhard's 
change of sound). The " cracked-pot " sound may be heard over large 
cavities with thin walls. 

Auscultation over small, lax-walled cavities shows cavernous, low- 
pitched breathing; over large tense- walled ones there is amphoric, high- 
pitched respiration. Moist rales depend on the contents, and are de- 
veloped or altered by coughing. Large cavities with smooth walls give 
"metallic tinkling." Pectoriloquy and amphoric whispers are heard 
over the largest cavities. 

Fever is present from the first and its height indicates fairly the 
activity and extent of the disease process. Chronic forms with slight 
or no tubercular infection show fever towards night and a normal tem- 
perature in the morning. Very high fever with hectic and night-sweats, 
or chills, indicates streptococcus invasion. Cessation of fever indicates 
quiescence of the malady, and if continuous, a cure. Sometimes chills 
occur so regularly as to induce the diagnosis of (quotidian) ague. Night- 
sweats follow fever of 104 or more, and are especially marked during 
destructive or septic stages. Wasting is also to be credited to the fever, 
being rapid in acute forms and becoming extreme in subacute. During 
apyretic intervals the patient may fatten considerably. Anemia comes 
from the fever and the impairment of nutrition. The blood may be nor- 
mal or deficient in hemoglobin. Leucocytosis occurs only in septic, 
suppurative states. Debility is progressive. 

Among concomitant phenomena may be mentioned tricuspid valvular 
disease, thrush, gastritis, early hyperacidity, later subacidity. Hectic sweats 
may alternate with bronchorrhea or colliquative diarrhea. Intestinal tuber- 
culosis may result from swallowing sputa. ' The appetite is feeble, capri- 
cious, the digestive power small. Anal fistula is not common. 
Albuminuria is common, and nephritis may eventuate, amyloid or des- 
quamative. Pyelitis or cystitis may occur from secondary tubercular 
infections. The face is pale, cyanotic sometimes in the later stages, 
the skin dry and harsh with chloasma on the chest, or pityriasis versi- 
color, the hair extraordinarily luxuriant, the nails soft or brittle, the 
finger-ends clubbed. 

The patient is singularly buoyant. The fever stimulates his mental 
faculties to unhealthy brilliancy. To the last he has a conviction that 
his malady is not "true consumption," and that he is going to recover. 



326 CHRONIC PHTHISIS 

Diagnosis: — The aspect of the patient, his family history, occupation, 
habitation, the physical signs of localized pulmonary disease in one apex, 
slight cough, fever, wasting, hectic, hemoptysis, brilliancy in evenings 
and night-sweats are all ominous; but in these modern days the diagnosis 
is made solely by the microscope. The X-ray is of value only in ad- 
vanced stages. The rise of temperature following the hypodermic 
injection of tuberculin is highly significant. 

PYOPNEUMOTHORAX 

History of pleurisy, 

Interspaces motionless and bulging, 

Apex beat displaced, 

Vocal fremitus less, 

Percussion note full and deep, 

Outline of dullness follows change of posture, 

Vesicular sounds and vocal resonance absent, 

Amphoric sound if air passes opening, 

Coin sound and succussion splash. 

LARGE PULMONARY CAVITY 

Immobile, flat chest, spaces depressed, 

Apex beat normal, 

More fremitus, 

Tympanic or cracked pot, 

Wintrich's change of sounds, 

Vesicular sounds and vocal resonance present, 

Bronchial sound increased, 

Crackling, gurgling, cavernous or amphoric sounds, 

Pectoriloquy, 

.No bell-tympany or splash. 

Prognosis: — Bad indications are the acuteness of the attack, rapidity 
of its progress, deficient resisting power of the patient, high and persist- 
ent fever, hectic, night-sweats, the presence of many tubercle bacilli 
and streptococci in the sputa, softening and cavity formation, compli- 
cations, inability to take and utilize needed food, disposition to substitute 
alcohol for food, age below or at puberty, bad hygienic environment 
and poverty. 

Death may occur from intercurrent disease, nephritis with hydremia, 
endocarditis, hemorrhage, angina pectoris, but usually is due to 
exhaustion. The course is most varied; one patient died in four days, 
while many survive for many years. Anders gives the average as three 
years. 

Liability: — The liability to tuberculosis is universal. 

We have known the strongest men, living the healthy life of farmers, 
without an instance of the disease in their ancestry as known for several 
generations, to become tuberculous within a year from the day they 
married consumptive wives. Nevertheless the predisposition to the 



CHRONIC PHTHISIS 327 

disease varies, and some are more liable to contract it than others. This 
is not always a question of strength, as the strongest of men may succumb 
to the attack of the bacillus when weaker men escape. When a student 
in Cleveland, one of our classmates, Lee Heavner of West Virginia, a 
great powerful man, of faultless habits, without preliminary ailment, 
was seized with tubercular phthisis and succumbed within the year. 
None of his classmates, exposed to the same influences, occupying the 
same room, was affected. His family was well known to be consumptive. 
In this case the evidence seemed to be conclusive that there was a 
hereditary predisposition and not an infection through residence in an 
infected house, for the man was not living at home when the disease 
attacked him. 

In many other cases the alleged inheritance is really a contagion, 
the patient being attacked while occupying the house, room or bed, in 
which a tuberculous person is or has been. Flick has accumulated much 
evidence showing that tuberculosis haunts certain houses, attack- 
ing successive families dwelling therein. If a consumptive emits billions 
of tubercle bacilli each twenty-four hours, it is easy to see how a house 
becomes affected. 

The liability to tuberculosis is greater in the children of consumptives, 
in scrofulous children, in those who are liable to epistaxis during child- 
hood, in those who are debilitated through disease and faulty hygienic 
environment, the rickety, cyanotic, etc. The liability is also increased 
by the occurrence of typhoid fever, measles, whooping-cough, and any 
other form of pneumonia. 

Contagion is favored by crowding together numerous persons, in 
badly ventilated places such as asylums, jails, factories, and sweat-shops, 
especially when poor feeding and depressing influences are at work. 
The milk and flesh of tuberculous cattle carry bacilli, and domestic ani- 
mals are frequently to be blamed with the infection of their owners. 

In the great majority of cases the attack may be credited to the inhala- 
tion of the bacilli given off with the sputa of consumptives. Less fre- 
quently the other excreta are the source of infection. W r hile the bacilli 
live for an unknown period outside the body, the influences fatal to them 
probably balance their reproduction, since the proportion of the human 
race that becomes tuberculous does not perceptibly increase. It is there- 
fore evident that if care were taken to destroy all the excreta of all tuber- 
culous patients an end would be put to the affection in time. 

TreBtment: — Consumptives should use a portable cuspidor. The sputa 
should be burnt; chemical disinfectants are less certain. The feces and 
urine should be passed into a vessel containing freshly made whitewash, 



328 CHRONIC PHTHISIS 

and allowed to stand an hour before emptying. When the patient va- 
cates his apartments, by death or otherwise, the disinfection should be 
as thorough as possible, the most satisfactory method being to burn the 
house. For this reason it is advisable that such persons live in inexpensive 
houses, of wood or of corrugated iron, with the simplest of furniture. 

No person should occupy the same bed as the consumptive, and the 
children of such patients should be taken to another residence if possible. 
They should be systematically hardened, by cold baths, salt rubbing 
and open-air life, carefully regulated exercise, scientific feeding and, in 
a word, all the resources of modern hygiene. Children predisposed to 
consumption are apt to be very "nice" about their eating. They should 
be taught systematically to discourage the eccentricities of taste, and to 
eat everything. Too often these peculiarities are encouraged by the 
mother, under the idea that they are evidences of some sort of superior- 
ity on the part of the child. The stomach is a creature of habit and may 
be trained to do its duty as readily as the child itself. Especially should 
they be taught to eat fats, which such children rarely do. At first the 
fat will cause indigestion, but by a few weeks ' persistence this will be 
overcome and the fat will be relished. Similar persistence will subdue 
the dislike for nearly if not all foods at first not relished, and the net result 
will be a stomach that will digest anything its owner thinks best to put 
into it; a very desirable state of affairs. 

There are three respects in which the choice of a climate influences 
the patient, whether he is already a consumptive or simply predisposed 
to that disease: First: All persons gain blood in an elevated locality, 
the blood becoming richer in red cells and in hemoglobin in high alti- 
tudes. We noticed with interest the brick-red complexions of all the 
inhabitants, especially the children, at Silver Plume, Colorado, over 
9,000 feet above the sea-level. 

Second: — All persons enjoy better health and resist the attacks 
of disease better, as they spend more time in the open air. Those who 
are predisposed to tuberculosis and those who still feel capable of making 
a fight for their lives should arrange their affairs so as to keep in the 
open air as much as possible. There are advantages even in the 
noble profession of the tramp, possibly even in that of the book-agent. 
That climate is best for each patient in which he or she can spend the 
most time in the open air. This embraces the consideration of heat 
and cold, moisture and dryness, sunshine and shade, etc. An equable 
climate, without sudden changes or extreme heat or cold, ♦with a maxi- 
mum of sunny days, with a dry atmosphere and a free circulation of 
air, is usually preferred. A thickly- wooded country would be objection- 



CHRONIC PHTHISIS 329 

able because there would be little circulation and much dampness. 
Taken altogether, the western slopes of the Rocky Mountains offer the 
most generally suitable locations, the patient following them south into 
Mexico as the fall approaches, and north into Idaho as the summer 
advances. 

Third: Individual preferences and peculiarities must be consulted. 
Broadly speaking, mankind is divided into two classes, the moun- 
taineers and seamen. Some improve the moment they reach the moun- 
tains and languish at the seashore, while others, perhaps in the same 
family, find the seaside suits them and do badly in the elevated region >. 
Along the Atlantic coast there are many persons formerly consumptive 
who have found health there and have wisely made it their permanent 
home. Others are to be found in the Adirondacks, in Minnesota, 
Colorado, Southern California, Arizona, Texas, the Gulf Coast, 
Florida, the West Indies, Old Mexico, and every other locality that 
has as yet been exploited as a "cure" for consumption. And in every 
one of these places are the graves of unnumbered dead, who have been 
allured by the glowing reports of the first enthusiasts who, finding 
health there, jumped at the hasty conclusion that their experience would 
be that of all who followed them. Beyond the principles laid down 
above, there is absolutely no benefit to be obtained from any climate, 
and the selection must be made on personal grounds entirely. It has 
not as yet been shown that any climate is specifically curative, or 
that any atmosphere has in it any element fatal to the tubercle bacillus, 
or is deficient in any element necessary to its vitality. 

The only rule deducible from our experience is that no person should 
be sent to any place that has acquired a reputation for the cure of con- 
sumption. The reasons are, the pollution of the air by the bacteria 
from the crowds of consumptives, the lack of proper accommodations 
from the same cause, and the depressing influence of seeing around one 
these fellow-sufferers, all animated by the hope of a cure, and most of 
them evidently deceiving themselves. For the marvelous hopefulness 
of the consumptive does not take in his consumptive neighbor; and 
when ones sees the others equally hopeful and yet failing every day, the 
pessimistic thought is apt to intrude, that he also has been deceiving 
himself, and pessimism is a fatal symptom in a consumptive. 

When the location has been selected, the patient must find some 
suitable occupation; and this is a matter of much importance. He 
ought to have a productive one, as he should be encouraged to 
look upon himself as a normal, self-supporting member of the 
community, and not as an invalid. Indeed, it is hard to say how 



33Q CHRONIC PHTHISIS 

far this principle can be carried with advantage, as even advanced 
cases have responded favorably to it. By rule, the patient should 
keep quiet and in bed while the temperature is up, and do 
his exercising in the morning, when the fever is down. Fatigue 
is also to be avoided, as the tubercle bacilli more readily over- 
come the resistance of the body when it is exhausted by any cause. 
Fatigue is therefore apt to be followed by a development of the 
malady.. The minute care that follows the patient about, checks him 
whenever he has had exercise enough, throws a shawl over him when 
heated or as the air grows cooler, keeps him in bed during the febrile 
period, and thus prevents taking cold, becoming fatigued and other pos- 
sible causes of backsets, has its place especially with advanced cases, 
and that numerous class that has no sense of its own to exercise. Never- 
theless, in this class we can but rarely look for a "cure." In the majority 
the result of our efforts is simply that prolongation of life and alleviation 
of its miseries that seem so much to the doctor and so little to the pa- 
tient. 

Though this method of management is theoretically correct, so strong 
is the influence of suggestion that some will improve by disregarding 
every precaution and deliberately forgetting that they are invalids. They 
go out every day, rain or shine, fever or no fever, persist in wandering 
over the mountains, eat all sorts of food with an out-door appetite, and 
by the force of will, of rousing the vital powers, and the influence of hope, 
they actually recover, the wounded lung cicatrizes, and they live out 
their allotted time. These are the exceptional cases. For one that is 
thus cured, twenty are killed by the same means. If the patient be of 
the timorous class that dreads death and wants to cling to every day 
that he may be kept alive, it is best to adopt the painstaking plan; and 
this is the only one for the advanced cases, for the weakly and indolent, 
and for those who are not likely to follow up the active plan with energy 
and intelligence. But for those brave souls that will only give up when 
life is extinct, who will die fighting if die they must, and will take any 
chance, small though it may be, rather than sit still and wait for death, 
the active plan is preferable. 

The diet of the consumptive should be rich in nitrogenous articles, 
care being taken that they are completely digested. There is a certain 
antagonism between uricemia and consumption, and the meats that 
produce uric acid protect against the graver affection. Milk is 
most useful if from cows certainly not themselves infected. Eggs, fish, 
oysters, rare meats, with acid-pepsin to aid digestion, are of special 
value. But these are not to be used to the exclusion of other food. 



CHRONIC PHTHISIS 331 

The most infinite variety of foods gives better results than any 
limited diet. 

The question of alcohol has been fought over for many years, but 
the view now held is that this agent does not in any manner aid the pa- 
tient, while it favors the occurrence of fibrosis and the destruction of 
the pulmonary cells. Its interference with nutrition is beyond question, 
while it destroys the appetite, the patient tending to gradually substitute 
alcoholic beverages for food. We never use alcohol in the treatment 
of consurnptives and rarely in any other affections. 

The use of nuclein in tuberculosis is based on the following consid- 
eration: Leucocytosis, the multiplication of the white blood cells beyond 
the normal number, takes place in almost every disease of bacterial 
origin, with the exception of tuberculosis. All these other microbic 
affections are self-limiting, again excepting tuberculosis. Is there any 
connection between these two facts? Metschnikoff, in his celebrated 
observations on the phagocytic action of the white cells, concluded that 
these bodies played the part of an armed force, ready to combat any 
intruding microorganism. Buchner followed with the observation that 
the blood-serum exclusive of the cellular elements could destroy disease 
germs. Finally Vaughan announced that by the administration of 
nucleinic acid the number and activity of the leucocytes could be 
increased. 

While the evidence is strong in favor of nuclein when given by the 
mouth, it seems wiser, in administering an agent whose action is so nearly 
if not altogether a vital one, to take no chances on its being destroyed 
by the gastric juice, but to give it by the more direct or hypodermic 
method; or dropped under the tongue. 

This, with reconstructive tonics, preferably the arsenates of iron, 
quinine and strychnine, and saturation with the sulphides of arsenic 
and lime, is the only direct treatment we have to recommend. The 
various forms of tuberculin have all failed to establish their efficacy, 
and have less in their favor theoretically than nuclein. The reports 
from Trudeau indicate that no more is to be said on behalf of the various 
serums tested at his sanatorium. Many capable workers are running 
out the possibilities in these lines, and it may be that they will ultimately 
hit upon something of more practical utility; but at present this is still 
"in the air." 

The endeavor to destroy the bacilli in the body by chemical germi- 
cides has resolved itself into the use of creosote and its derivatives, 
especially guaiacol. Out of many cases treated with these agents a few 
have been cured. These have been individuals who exhibited a remark- 



332 CHRONIC PHTHISIS 

able tolerance of the drug, and very large doses were given for long 
periods, until the patient was saturated with it. One woman thus 
treated smelt like a ham and her skin was the color of dried beef. Few 
stomachs can bear these large doses of creosote and guaiacol, but oleo- 
creosote, the carbonates of creosote and guaiacol and other derivatives 
have proved more agreeable. Whether they are as effective also we are not 
quite sure; but we have obtained excellent results from them in some 
cases, pushing the doses up to the limit of toleration; for if benefit is to 
be expected from a germicide it should be given to bring the body under 
its influence as quickly as possible, to attain such a degree of saturation 
as will render it impossible for the bacillus to live in it. 

The most potent agents we have yet found are the sulphocarbolates. 
The discovery of their usefulness was accidental. We had reason to 
fear that by swallowing sputa a patient would infect his intestinal canal, 
and to prevent this we gave him zinc sulphocarbolate, which we had 
long used as an intestinal antiseptic. With the disappearance of odor 
from the stools the fever dropped, the appetite and digestion improved, 
and the general improvement followed that is seen in other cases of febrile 
disease when intestinal antisepsis has been produced. For three years 
this patient has taken the sulphocarbolate of lime, forty grains a day, 
and in that time she has never missed a meal or had an indigestion. The 
calcium salt was chosen because the fragility of her tissues demanded 
lime, and it agreed with her stomach. We have since made the sul- 
phocarbolates a standard prescription in all cases of consumption, and 
have been abundantly satisfied with the results. 

Iodoform is a remedy that has been recommended by many clin- 
icians, on different grounds. It is, in part at least, eliminated by the 
lungs, favorably affecting the cough, stimulating the absorbents, and 
possibly acting in some degree as an obstacle to the multiplication or 
to the activity of the bacilli. There is an unusual tolerance of this agent 
in consumption, and we have given five to twelve grains daily for months 
without the production of iodism. 

Many observers have noted the virtues of strychnine as a general tonic, 
improving the appetite and digestion, checking the fever and the night- 
sweats, as well as the tendency to colliquative discharges by the skin 
or the bowels, etc. We have found it decidedly advantageous to give 
strychnine arsenate, gr. 1-30, three to seven times daily. 

Fever is not so much due to the direct effects of the bacilli as to 
the absorption of septic products. It is necessary therefore to keep the 
purulent matter cleared away as thoroughly as possible. The pulmonary 
tract may be cleared out by inhaling the fumes of boiling vinegar for 



CHRONIC PHTHISIS 333 

five minutes or more every night just before retiring. This removes 
the collected secretions, and the patient has relief from the cough for 
some hours, perhaps until the next morning. Advantage may be taken 
of this to try to reach the affected tissues with local remedies applied 
by the atomizer. We usually employ an oil atomizer charged with a 
mixture of europhen in fluid petrolatum, one part to eight, and spray 
with this for five minutes. Some few patients find great relief from 
inhaling the fumes of burning sulphur, and this should be of great value 
as a germicide, but most persons are unable to bear even a slight inha- 
lation of this irritant gas. 

The foregoing treatment, aimed at its cause, generally reduces the 
fever to a safe point; so that direct treatment of this symptom is not often 
required. In case an antipyretic is needed, however, from five to ten 
drops of guaiacol may be rubbed into the skin, in the clavicular region. 
This produces so decided a fall of temperature that some caution should 
be exercised in its application. Or, five grains each of guaiacol and 
piperazin may be given in capsule every four hours. The reduction 
of the temperature in this manner is more decided and lasts longer than 
when Niemeyer's pill, quinine alone or any of the synthetic antipyretic 
of the anilin series are given. 

The cough may be treated on general principles, giving codeine, the 
cyanide of zinc, cannabis, or steam inhalations to soothe irritation; 
emetine or lobelin to stimulate secretion; sanguinarine to arouse sensi- 
bility and cause retained secretions to be ejected; atropine or aspidos- 
permine to allay dyspnea; strychnine and cubebin to restrain excessive 
secretion, etc. The uses and causes of a cough should not be forgotten. 

Indigestion, diarrhea, etc., cease to be prominent symptoms of con- 
sumption when the general treatment advised is employed. 

And with all this done, what is the net result? What hopes can we 
hold out to our patient? Will he in spite of it all simply delay his steps 
awhile, and then rejoin that innumerable caravan that is steadily march- 
ing along the road to the consumptive's grave? 

We are entirely too gloomy in our prognoses of consumptives. Whit- 
taker says that it is shown by the records of many thousands of autopsies 
that two-thirds of the human race suffer at some period of their lives 
with tuberculosis, and that one-half of these examinations show that 
the disease has been cured. This gives a general mortality of fifty per 
cent. Admitting the correctness of the gentleman's figures, it is difficult 
to get away from his conclusions. 

We can now look back over a period of thirty-five years spent in the 
study and practice of medicine. We have attended many a consump- 



334 CHRONIC PHTHISIS 

tive to the grave. But throughout our professional life we have seen 
cures; at first not admitted, as the conviction was so strong that the dis- 
ease was incurable, that the diagnosis was denied if the patient recovered. 
This, of course, effectually "jugulated" all the chances of establishing 
a successful method of treatment. But since the discovery of the bacillus, 
easily determined by the use of reagents and the microscope, we can pro- 
ceed on the basis of certainty as to diagnosis, and maintain our claims 
of success. And this enables us to assert that our earliest claims were 
well founded, and that consumption has indeed been cured many times 
when the doctor allowed himself to be "bluffed" out of the results of 
his labors. 

It is also evident from this retrospect that there has been a progres- 
sive improvement in the results, as the methods and the skill of the doctor 
improved with experience. Cures have been more frequent, and the 
average life of those who were not cured has been longer. And since 
everyone must expect to die sometime, the importance of this latter 
statement is greater than at first sight seems obvious. Let it be under- 
stood that in each case the prime object is not so much to kill a swarm 
of invading microorganisms, or to restore a diseased organ to an impos- 
sible condition of perfection, a return to the statu quo ante bellum, as it 
is to best utilize and promote the patient's remainder of vitality, to extend 
his life and capacity to work and enjoy to their utmost possibility. If 
this be fully comprehended by the doctor and his patient, the problem 
assumes a somewhat different aspect. Many a valuable life has been 
wasted in the vain attempt to win an utterly impossible "cure," when 
under proper management the patient might have lived to the full limit 
of his expectancy. 

How to live the best and longest with tuberculosis is often our study. 
In this is involved the proper care and treatment of all classes of cases, 
from those that can be entirely and permanently cured to those who go 
down rapidly to the grave. 

From the treatment outlined in this paper the writer has had better 
success than from any method previously employed. The improvement 
in some cases is almost past belief. In some, the bacilli in the sputa 
grow scarcer at each successive examination and finally disappear; the 
symptoms showing a corresponding course. In others the bacilli decrease 
until very few remain, but these few persist obstinately. No case in 
three years submitted to this method has failed to improve very much. 
Cases of mixed infection have received in addition such treatment as was 
indicated. 






CHRONIC PHTHISIS 335 

CAMP AND SANATORIUM TREATMENT OF CHRONIC PULMONARY MALADIES 

It has been shown conclusively that exposure to sunlight is destructive 
to tubercle bacilli, while it increases the vital resistance of the patient. 
Denison says that when cattle are confined to stables they become tuber- 
culous, but when taken from their stalls and sent out to graze on the open 
prairie they gradually recover, so that tuberculosis becomes extinct on 
the ranges. 

Local tuberculosis of the skin has been treated by exposure to the 
actinic rays with some success. The effect has been attributed to the 
germicidal action of the chemical rays, just beyond the violet, to the in- 
creased supply of blood thus attracted to the skin, and to the effect of 
the light upon the blood. In the laboratories, light must be excluded 
or the cultures are lost. It is obvious, therefore, that the climate best 
suited for consumptives is that where they can enjoy the most sunshine. 

Kime very rationally contends that to secure the benefits of sunlight 
the patient's body should be exposed to it, and not merely his clothes. 
He has demonstrated that when concentrated the actinic rays pass en- 
tirely through the human body, with sufficient intensity to reproduce a 
picture on a photographic dry plate. The skin offered most resistance, 
the muscles less and the bones the least. By using blue light a large per- 
centage of the actinic force is utilized, with little of the heat, which is 
strongest in the red rays. Kime is in doubt as to whether the rays kill 
the tubercle bacillus directly or simply by stimulating phagocytosis; but 
in skin tuberculosis he is positive as to the curative action, the malignant 
ulcer being converted into a simple one. In one of his cases three treat- 
ments of ten minutes each, with a blue lens near the cautery point, effected 
a cure within three weeks. 

Abrams reported cures of tuberculous lymphatic glands by this agent. 
Whether the method will prove as successful in the treatment of pul- 
monary tuberculosis remains to be seen; though the early reports are 
encouraging. The question is most important, as, if the advantages ■ 
of climatotherapy can be thus secured at any place, its benefits may be 
extended to the enormous majority who cannot leave their homes. 

The value of a residence in elevated regions lies partly in breathing 
the rarefied air. This stimulates the respiratory apparatus and develops 
it, so that mountaineers are noted for the fine development of their chests. 
This is imitated in the pneumatic cabinet, which the patient enters and 
the air is rarefied by an exhaust pump. This is said to be a very effec- 
tive remedy for pulmonary hemorrhages, but at the best it is but a paltry 
substitute for the mountaineer's life, with its sunlight, pure, cool air, 



336 CHRONIC PHTHISIS 

exercise in climbing, with the consequent appetite and digestion. An 
hour or two spent in the cabinet is of benefit, but living on the mountain 
for 24 hours of each day is that much better. 

The cabinet permits the use of medicated inhalations but these are 
managed easily without it. In the cases where we have employed the 
fumes of burning, sulphur we have been surprised at the ease with which 
patients withstood them. Personally the smallest trace of the fumes 
in the air will set up the most violent coughing, which will last long after 
leaving the room; but some tuberculous patients breathe with comfort, 
and absolutely with liking, air thick with the gas. The inhalations gen- 
erally give marked relief, and the symptoms are ameliorated, sometimes 
for weeks or months afterwards. 

The great value of Finsen's light-cure lies in the patient's being 
treated at his home, where he is under the doctor's watchful care. In 
the vast majority of cases this is the first essential. Few men or women 
know how to live hygienically. Still fewer do it, even when healthy. 
In chronic disease of the lungs the regulation of the life is everything. 
Fatigue seems always to be followed by a renewal of the malady, as if 
the little enemies were ever ready to seize a favorable opportunity to 
renew their attacks. A lazy indoor life saps the vitality also; so that to 
steer between the two difficulties, securing the maximum benefit of out- 
door exercise and avoiding fatigue, requires a nicety of judgment rarely 
seen outside of the medical profession and not too often within its ranks. 

Then again, few consumptives know how to vary their clothing with 
the changing weather, how to get the greatest benefit from their food 
without overtaxing the digestive organs, how to train the stomach pro- 
perly; in a word how to give their personal habits that minute and intel- 
ligent care they demand, and yet not become hypochondriacs or valetud- 
inarians. Is it not all summed up by saying that the consumptive must 
have a doctor to do the thinking for him, in so far as his malady is con- 
cerned ? 

We have said that the best climate is that which affords the largest 
proportion of sunshine. Add to this the benefit of mountain air, and 
we will find what we seek in the elevated regions of the Rocky Moun- 
tains, along their entire extent. In summer the patient can go north, 
and ascend higher to secure coolness; in winter he must go south, or 
descend to the foot-hills. In Northern New Mexico, at Aztec, on Las 
Animas river, some consumptives have regained health. This table- 
land is about 6000 feet above the sea ; it is cooled in summer by the breezes 
from snow-clad mountains and protected by them from excessive wind. 
The winters are mild, with but little frost, so that with the aid of an 



CHRONIC PHTHISIS 337 

oil-stove patients can live in tents the whole year. The soil is sandy, 
drainage good, water alkaline. Fruits of all kinds nourish on the soil 
watered by irrigation (by private ditches, not by corporations). The 
air is dry, the sandy plains extracting the moisture. No great rush has 
yet occurred to this region, so that it is as yet unpolluted. 

Arizona is well suited for winter residence, but too hot for summer. 
Along the mountains thence down into old Mexico can be found many 
ideal localities, for those able to care for themselves and secure their own 
food. Those able to hunt can find game in abundance, but outside the 
States they need not expect hotels or American food. For those who 
can endure and enjoy the life of the hunter and prospector, health is to 
be found in these regions. 

For the delicate, women and advanced cases, it is wiser to go where 
the comforts of civilized life can be procured. Florida, our new island 
possessions in the West Indies, Cuba and the Lesser Antilles, offer many 
eligible locations, where the patient may enjoy life, obtain its luxuries, 
accomplish a cure when still possible, and prolong life and its enjoy- 
ment to the greatest extent when a cure cannot be secured. In other 
words, a residence here is pleasant, and offers the best chances for a cure 
to those not calculated for the rough life of a hunter. 

We know of no work so well suited as a guide-book than the one 
written by our old friend W. F. Hutchinson, under the title of "Under 
the Southern Cross." Dr. Hutchinson for many years spent the winters 
in the West Indies, Central or South America, and gave in this book 
exactly the information one wants — where, when and how to go, hotels, 
prices, pleasures, dangers, how to dress, etc. The book was published 
by Appletons. 

Porto Rico deserves especial attention. Its hills should prove es- 
pecially suitable for the winter homes of invalids. Probably many open- 
ings for the profitable employment of convalescents with some capital 
will be found there. 

Robert Louis Stevenson sought health in the islands of the South 
Pacific, and found there a grave. Nevertheless, he undoubtedly lived 
longer and more comfortably than if he had remained in the North. 
The climate of the Philippines is hot and damp, and under such in- 
fluences the disease progresses rapidly, the bacteria multiplying fast. 
But there are many islands where eternal spring reigns, and if one can 
bear the isolation the conditions are most favorable to a cure. But — 
one young man we sent there returned; and when we asked him if he 
knew he came back to die, he said, "yes, but I would rather die in God's 
country than live there, " 



338 CHRONIC PHTHISIS 

Some persons care more for life than for human society, but this mat- 
ter should be considered carefully before advising. If the patient, fore- 
warned chooses life, let him be sent to seek out a suitable place, and when 
there adopt the native costume of a bracelet or two, and let the sun exert 
its full power. To some of us who have had fifty years of not overly 
pleasant experience with humanity, a Crusoe-like life on an ocean island, 
with a shipload of books and other necessaries, would not seem so un- 
desirable. 

In prescribing a camp life several important objections are advanced 
by Von Ruck, such as the difficulty of obtaining a constant supply of 
fresh meats, milk, cream, butter and other stores, and preserving them, 
keeping the camp in a sanitary state; taking colds; care for acute attacks; 
shifting location with the season; to which may be added the questions 
of accessibility, aid in case of need, and the intrusion of hostile or curious 
visitors. In truth, camp life suits but a limited class. Even so, the time 
required for a cure is long, by no means limited to a few months; and 
when one has been cured there will be found an increased liability to 
relapse, when the whilom patient returns to the germ-laden air of civil- 
ization. He has lost his immunization by breathing pure air. 

Brooks enumerates the following essentials for sanatoria designed 
for consumptives: 

i. There should be a good southern exposure. 

2. The soil should be well drained and preferably of gravel. It 
is, of course, essential that the foundations should be dry. 

3. There must be free access of sunlight. 

4. The "camp" for the Liege und Dauerluftkur" should be situated 
in the open, but protected from the north and east winds. Glass covers 
to the verandas are not necessary. 

5. There should be facilities for walking, preferably through the 
woods, and if possible up a slight incline from the sanatorium, so that 
the homeward journey may be down hill. There should be facilities 
for resting at easy distances. 

6. The diet should be most carefully regulated. Feeding should 
be slightly in excess, but the food should be well selected, nutritious, 
temptingly served and, of course, properly cooked. 

7. There should be large, airy, individual sleeping apartments, af- 
fording free admission of sunlight. 

8. Every patient must be provided with an individual spitting-cup, 
and forbidden upon pain of immediate dismissal to spit anywhere else. 

9. There should be withal scrupulous cleanliness, adequate service 
and regular disinfection. The furniture should be somewhat severe. 



CHRONIC PHTHISIS 339 

Carpets, brooms and hangings have no place in a well organized sana- 
torium. Cloths, dampened with antiseptics, should be substituted for 
dusting. 

10. There should be a routine of occupation, together with simple 
diversions, to prevent introspection. 

Much, very much, could be said in favor of the sanatorium for con- 
sumptives. The constant supervision, the watchfulness over the develop- 
ment of the malady and prompt application of suitable remedies, all 
by one skilled in the management of these cases by daily association 
with the patients, all this is of incalculable value. 

All that can be urged against the sanatorium may be embraced 
under the single head of mismanagement. If the destruction of sputa, 
the daily fumigation of the living rooms, and the other measures to pre- 
vent the infection of the premises and reinfection of patients, are not 
carried out perfectly, the sanatorium is about the most dangerous place 
the consumptive could find. A patient once informed us that every 
morning the servants in a popular " sanatorium" could be seen mopping 
up the sputa from the halls, corridors and public rooms! 

But with proper management such an institution offers the very best 
chances for the cure of the consumptive, and we believe the per cent 
of cures there largely exceeds that obtained by the camp method. Under 
the use of the treatment herein advised the bacilli in the sputa become 
fewer until they disappear, the symptoms and general condition of the 
patient showing corresponding improvement. Keep him in the sana- 
torium until this has been accomplished, and he has been taught thor- 
oughly the lesson of how to care for himself; then send him to the camp. 

What after all do we mean when we speak of a cure for consump- 
tion? The bacilli may disappear, the cavity scar and contract, the 
disease become obsolete. But the bacillus always lurks for an oppor- 
tunity to reinfect his victim; the predisposition that originally deter- 
mined the attack remains; the congenital vulnerability of the tissues 
has not lessened. Hence the patient who has been cured of phthisis 
still remains more liable to a fresh attack than the person who has never 
suffered from the malady; more, even yet, when he sojourns in a bacteria- 
free atmosphere he loses the degree of immunity he has enjoyed while 
constantly exposed to the action of the bacilli, and when he returns to 
the inhalation of air thickly inhabited by them, they find his leucocytes 
unprepared U» resist their onslaught. Hence the cured consumptive, 
who wants first of all to continue living, should find an open-air life that 
he is content to adopt for the remainder of his days, and henceforth 
eschew the "busy haunts of men." There must be no hankering for 



3 4o CHRONIC PHTHISIS 

the flesh-pots of civilization; he must be a solitary wanderer on the face 
of the earth the rest of his days. 

MANAGEMENT OF THE PREDISPOSED 

One of the most serious problems before the physician is the care 
of persons not yet consumptive but predisposed to become so. These 
are the weakly children born of consumptives; of parents weakly, drunk- 
ards, greatly differing in age; in families where the new baby comes 
regularly every year or less. The children are frail, teething late and 
badly, walking late, the sclerotics blue, the skin thin and transparent, 
the veins showing through, under-sized, precocious in studies and too 
weakly to take part in the rougher games of their companions, subject 
to epistaxis and gastrointestinal attacks. The skin sometimes has 
a soft, greasy feel, and emits a catarrhal odor. The eyelids may be 
eczematous. The chest is flat, the lung-power below the average. 

Some of these children suddenly shoot up to unusual height, but this 
only emphasizes the defective chest-capacity. They are usually very 
nice about eating, liking few things, avoiding fat and coarse vegetables. 
Some, however, are gross, the face pimply, the neck seamed with the 
scars of glandular suppuration, the habits gluttonous, with indigestion, 
biliousness, and uricemia habitually 

Very rarely the florid type develops, with a complexion whose rich 
olive and high color has a brilliancy that is wonderful. These people 
generally get the reputation of using cosmetics, or " eating arsenic," to 
explain the unnatural beauty of the skin. One remarkable case of this 
variety died of Pott's disease; two others are married, mothers, and seem 
to have safely passed the dangerous period. All were girls. We have 
never seen or heard of a male case of this description. 

We have always looked upon the essential point of this predisposi- 
tion to phthisis as being a deficiency of lime, the element to which the 
cells of the body owe their strength. If the lime is deficient the cells 
are fragile, they break down easily, the skin breaks on slight irritation 
or exposure to cold or wet; the bones ossify slowly, the teeth are slow 
in erupting and decay soon. 

It has been noted that consumptives rarely have good teeth. We 
have also noted that never once in over 35 years' practice have we seen 
a case of cervical adenitis in a person with sound teeth; so that we have 
learned to look on the decaying teeth as an open door of which tubercle 
bacilli often avail themselves. The tonsils form another open door; and in 
their crypts may be found the original site of many a tubercular invasion. 



CHRONIC PHTHISIS 341 

The deficiency of lime is not due to its scarcity in the food or drink, 
for this element is often in excess in hard waters, and is present in every 
ordinary meal in sufficient proportion for the bodily needs. The difficulty 
is in its assimilation. This may be partly remedied by giving an excess 
of lime with the food, or by giving this element in the most manageable 
form. Experience has shown that while a large proportion of fat, lime, 
iron, etc., passes through the alimentary canal and is ejected in the feces, 
the larger the quantity swallowed, the more will be absorbed. If, for 
instance, one grain of iron be given daily, but one-tenth of a grain may 
be absorbed, but if ten grains be given one-tenth of this, or one grain, 
will be taken up. 

So with lime. Give a superabundance of it, preferably as lactophos- 
phate, the form experience has shown to be most easily dissolved in the 
body-fluids. Let the child be taught to suck soft bones of young animals, 
and chew off as much of them as possible. Powdered bone would doubt- 
less also be useful if it could be procured at a reasonable price. Marrow 
on toast or in soup is usually relished by any one. More lime will be 
absorbed if given in numerous small doses than in a few large ones. A 
granule of calcium lactophosphate, gr. 1-6 every half-hour, does more 
good than gr. 5 thrice daily. . 

We have many times noted the good effect on such delicate infants 
of daily inunctions with oil. It seems reasonable that a thin animal oil 
will be more readily taken up by the skin and utilized than a thick or 
vegetable grease; so that cod-liver oil, lard oil or goose-grease, is usually 
recommended. They may be rendered inodorous by adding a little 
eucalyptol or any volatile oil. The inunctions should be kept up through- 
out the winters, and as long as the child appears to require them. For 
older patients a woolen undershirt may be saturated with the oil and 
covered with oiled silk to protect the outer clothes. 

Even more important is the regime by which the child is strengthened, 
its power of assimilating the food-elements increased, and the tissues 
rendered more resistant to morbific influences. The diet should be 
carefully regulated to the needs, and the child taught to eat all varieties 
of wholesome food. Dislikes are soon overcome by having the child 
eat one very small morsel of any food it dislikes, or that it does not digest 
readily, at every meal. Especially should it be thus trained to eat fats 
of every description. A well-trained stomach is the most secure form 
of life-insurance. 

Hot salt baths keep the skin in good order, and bring the blood to 
the surface for aeration. These may be gradually replaced by dry rub- 
bings, with towels dipped into brine and dried, and in midsummer the 



342 CHRONIC PHTHISIS 

cold bath may be begun. This should be looked upon as strictly a thera- 
peutic measure, not a means of purification. The ideal cold bath is a 
quick plunge, shower or douche, of momentary duration, a quick in- 
and-out-again, followed by brisk rubbing or slapping to bring about 
strong reaction. If commenced in midsummer the baths may safely be 
continued the year round. 

The effect is to increase oxygenation, stimulate a more active circu- 
lation, put the skin in a healthy condition, and by accustoming it to cold 
render the patient less susceptible to catching cold. The sense of strength 
and well-being following the cold plunge stimulates the child to greater 
physical activity, and arouses the desire for free out-door sport. More- 
over the moral effect is by no means unimportant. No child at first 
can look on the prospect of a cold plunge without shrinking; and the 
necessary nerving one's self up to do a disagreeable thing because 
it is a right thing to do, is a lesson that cannot be learned too early 
in life. 

The love of out-door sports and occupations should be sedulously 
cultivated, and yet over-exertion as sedulously avoided. 

It does seem as if a most useful innovation in our school system would 
be the making of domestic and' personal hygiene a leading study, with 
practical demonstrations, and such exercises as would compel the pupil 
to really comprehend its meaning, instead of a perfunctory topic slurred 
over once a week, hastily, that the pupil may get back to the "classic" 
topics; the real value of which in the adult life is incomparably smaller. 
We would have every pupil compelled to measure the air-space of every 
living room in his home, and calculate its capacity for those dwelling 
therein, with the average consumption of oxygen by firelight and respira- 
tion; the ventilation; test the drinking water; examine the dust micro- 
scopically and bacteriologically; examine the food chemically and micro- 
scopically — in a word we would make him comprehend hygiene, even 
if he never learned to expand the binomial or even to enumerate the Kings 
of England. 

Gymnastic training is of value, to expand the chest and develop the 
body symmetrically; but here also good sense must rule. Compare 
on the one hand the consumptive pugilist Needham, the only man who 
ever won a decision in the ring against Tom Sayers, and the fact that 
so many trained athletes die consumptives. Needham, by carefully 
developing his powers to their utmost healthy limit, accomplished his 
object. Many athletes, by attempting to develop themselves beyond 
their natural powers fall victims to the bacillus, to which the exhaustion 
of over-training offers a most excellent opportunity. 



CHRONIC PHTHISIS 343 

The selection of an occupation should be made with the advice of 
the physician. We are too well aware of the execration that one would 
incur, by advising any one to increase the number of book-agents or 
peripatetic dealers in anything, but really the life is nearly an ideal one 
for our ci-devant prcdisposed-to-consumption, who yet is not prepared 
to take to the hunter's or prospector's life. In the millennium the noble 
profession of the tramp may become respectable; or perhaps a really 
useful form of tramping may be devised, as of a youth we once knew 
who regained health as a peripatetic varnisher. There are many such 
things that would make a workman welcome at the farm-house. 

Space forbids a detailed description of the useful gymnastic methods, 
but a few words must be said of respiratory exercise. Indian club swing- 
ing develops the chest-muscles admirably, and has the great advantage 
that the patient can have the clubs ready for a five-minute swinging at 
any hour, and many times a day. Always stop short of fatigue, and use the 
clubs for short periods and but few times a day at first, gradually increasing 
the length and frequency of the exercises as the muscles develop. 

Let the child be taught to breathe through the nose alone, to hold 
the head well up, and to slowly inhale until the lungs are fully distended, 
five or six times in succession, alter every club-swinging. Carrying 
something balanced on the head is an excellent means of cultivating 
an erect carriage, and if the weight be gradually increased the spinal 
supports are thereby strengthened. 

Athletic contests, football, wrestling, boxing, etc., are usually to be 
avoided, though tennis, golf, hand-ball and base-ball are useful. The 
rule is that the youth must avoid all exercises that strain his muscles, 
or try them to the limit of their capacity. All his work must be easily 
within this limit, and neither his own ambition nor the taunts or per- 
suasions of his comrades must be allowed to provoke him to the full dis- 
play of his strength. The best way to insure this is to teach the boy 
to look on exercise and sport as means for attaining health rather than 
as exhibitions of prowess. 

For these subjects a residence in the mountains is always advisable. 
The chest develops best by breathing the thin air of elevated regions. 
The blood is better oxygenated there, so that the brick-red complexion 
of dwellers over 8000 feet above sea-level excites the wonder and admira- 
tion of lowlanders; and the pure air offers few chances for infection. But 
woe to the mountain-bred youth who leaves his hill-tops to reside in the 
crowded city. He is doomed to the consumptive's grave. The moun- 
taineer's pining for his native hills of which the poet has so often sung 
is strictly physical in its basis, and easily comprehended by the pathologist. 



344 PLEURISY 

V. DISEASES OF THE PLEURA 

PLEURISY 

All inflammations of the pleura are attributable to microorganisms. 
In the exudate have been found tubercle and typhoid bacilli, strepto,- 
staphylo — and pneumococci. In emphysema the ordinary forms are 
micrococcus lanceolatus and streptococcus. Less common are the colon 
bacillus, proteus vulgaris, gonococcus and Friedlaender's bacillus, with 
several saprophytic bacteria. In half the cases more than one form is 
present. 

DRY PLEURISY 

• 
In acute plastic pleurisy the inflamed surface is injected, dull, with 

bloody points, covered with a fibrinous exudate, which thickens from 

friction, becoming shaggy, yellowish or reddish-gray. Embryonic cells 

in the exudate develop new vessels and connective tissue. The opposing 

surfaces adhere in severe forms; in lighter cases the exudate becomes 

fatty and is absorbed. 

This form of pleurisy rarely occurs primarily, from cold, or with a 
diathesis present. Secondarily it occurs with pneumonia and other 
pulmonary inflammations and with tuberculosis, when they extend to 
the pleura. In rheumatism, nephritis and alcoholism it is common, 
and it may also follow other serous inflammations. 

The symptoms are of all degrees of severity. The pleuritic stitch 
in the side is noted. The pain is increased by chest-movement, hence 
breathing is restrained and cough suppressed. When the opposing 
surfaces have become glued together this is relieved. The fever ranges 
from 101 to 103 degrees — often it is hardly noticeable; pulse 90 to 100, 
small and soft. In many cases the disease is "latent" and the patient 
really never knows he is affected; while in some there is the evidence of 
a serious malady, fever of 104 degrees, chills, prostration, and other symp- 
toms of corresponding gravity. 

The chest-movements are restricted, percussion note unaltered, but 
a friction sound is heard in the early stages — the " dry-leather " rubbing, 
heard most clearly at the end of the inspiration. When exudation occurs 
fremitus is said to be diminished and some dullness to be detectable, 
but it must be quite unusual for enough exudation to appear to render 
this possible. Friction is then heard on expiration and inspiration. If 
the exudation is abundant enough to compress the lung there may be 



DRY PLEURISY 345 

bronchial breathing, and it may require a delicate diagnosis to deter- 
mine if this is the case or the adjacent lung is pneumonic. 

The diagnosis is made by the friction-sound, stitch, suppressed dry 
cough and respiration, with the absence of evidences of pneumonia — 
crepitus, rusty sputa and dullness. Intercostal neuralgia has tender 
spots, but no friction sounds or fever. 

The attacks run on from a few days up to some weeks, and end in 
resolution with absorption, permanent adhesion of the opposing pleural 
surfaces, or death. A predisposition to subsequent attacks remains. 

Treatment: — Put the patient to bed; limit the pain and spread of 
inflammation by applying as tightly as possible a bandage or corset to 
the chest, as in fracture of the ribs; relieve the pain if severe by leeching 
or cupping over the painful region and reduce the hyperemia to the lowest 
point by rapidly reducing the bulk of the blood. Our fathers did this 
by bleeding and in many cases this is a wise procedure to-day, but not 
in diathetic or cachectic cases, or in individuals whose vitality is deficient. 
Better enjoin the dry diet, total abstinence from fluids and bulky or watery 
food, give a brisk, quick-acting cathartic, and enough pilocarpine to 
induce free sweating, gr. 1-30 every ten minutes till full effect. With 
this relax the contracted capillaries (vasomotor spasm) by aconitine 
amorphous, gr. 1-134, restore contractility to the vessels in thehyperemic 
area (vasomotor paresis) by strychnine arsenate, gr. 1-134, anddigitalin, 
gr. 1-67, and if needed subdue excessive heart-action and arterial tension 
by veratrine, gr. 1-134, given together every quarter, half, one or two hours, 
as indicated by the severity of the symptoms, till the desired effect is 
manifested. Here again we have an illustration of the singular fact that 
antagonistic remedies may be given together and each be appropriated 
by the tissues requiring its aid to restore physiologic equilibrium. 

During convalescence respiratory gymnastics should be employed 
to restore the expansion of the lung and prevent adhesions. A full, long 
breath or two, taken every two hours, is a useful measure. Iodine and 
mercury, the great absorbents, should be applied locally and taken inter- 
nally. The official compound iodine ointment, with a scruple of mer- 
cury biniodide to the ounce, may be rubbed into the skin twice a day. 
Internally iodoform, hydriodic acid, the iodide of iron, mercury, calcium 
or arsenic, may be given as indicated, alone or combined, the object 
being to get the greatest possible effect while the exudate is still young 
and amenable to treatment. We usually cover the skin over the affected 
region with belladonna plaster containing camphor, and have this worn 
for a month or more on dismissing the case. Bearing in mind the fre- 
quency of tuberculosis as a cause or sequence of this malady, we rarely 



346 SEROUS PLEURISY 

allow a patient to be beyond observation for a year after such an attack, 
and employ the measures usual for persons prone to that malady — diet, 
personal hygiene, occupation, climate, etc. 

SEROUS PLEURISY 

While in the affection last treated a portion only of one pleura is 
affected, in the effusive form the whole of one sac participates in the 
inflammation. The malady is by that much the more grave. The 
pathological changes are similar, save that the exudation is more copious 
and serous, with a fibrinous layer of varying thickness on the surface 
of the affected membrane. The fluid contains varying amounts of fibrin, 
and may be but a few ounces, or several quarts, in bulk. It is clear or 
turbid, water- white, yellowish to brown. At first it settles in the most 
dependent parts, and if the whole sac is not filled, inflammatory adhesion 
takes place, confining the fluid there, so that it no longer changes its level 
with the changes in the patient's posture. This differentiates the malady 
from hydrothorax. In the fluid are found white and red blood-cells, 
fibrin, albumin, endothelial cells, sometimes cholesterin and uric acid 
crystals. Its composition is that of blood-serum, simple or con- 
centrated. 

If copious enough, the fluid causes .compression of the lung, pushes 
the heart and mediastinum toward the opposite side and the diaphragm, 
liver or stomach downwards. 

The causes are similar to those of fibrinous pleurisy. Exposure to 
cold or wet and traumatisms are excitants. Many cases are due to tuber- 
culosis, primary or following the same infection in the lungs or elsewhere. 
Pleurisy also occurs with rheumatism, pneumonia, typhoid fever and 
pericarditis, or nephritis, cancer and cirrhosis of the liver. 

Symptoms: — In secondary pleurisy the attack may be masked by 
the primary disease. In primary attacks the onset is also often insidious, 
rarely sudden, with chills and high fever. The stitch in the side follows, 
becoming worse on exertion or drawing a long breath. Dyspnea follows, 
with voluntary restraint of breathing and coughing. The sputa are 
scanty, mucous, sometimes blood-streaked. The fever is of medium 
intensity, higher in evenings, the pulse rapid and small. In latent forms 
there may be a decline in health for weeks before the malady is recog- 
nized, with anorexia and emaciation, or headache and dyspeptic symp- 
toms. Remissions may occur, with relapses, each leaving the level of 
the effusion higher, until the whole sac is full of serum, the lung pressed 
solid. 



SEROUS PLEURISY 347 

The stitch is not noted in the insidious form, and disappears when 
the effusion separates the inflamed surfaces. The breathing is restrained 
before effusion, shallow and somewhat hurried afterwards, dyspneic 
if the effusion is profuse and rapidly thrown out. But fever has as much 
to do with the production of dyspnea as has the actual pressure on the 
lungs. Cyanosis, however, depends solely on the latter. The cough 
is dry unless bronchitis coexists. The fever is not high, is usually regular 
in range, and subsides by lysis. On the pleuritic side it is somewhat 
higher than on the other. The pulse corresponds with the fever, the volume 
and tension are lowered. Pressure on the heart and great vessels may occa- 
sion irregularity. The appetite is poor, the bowels confined. The 
urine is lessened, the specific gravity high until absorption begins, when 
diuresis occurs. 

The physical signs are the same as in plastic pleurisy, except that 
in the serous form there is dullness corresponding with the effusion, the 
intercostal spaces bulge, the respiratory movements are absent. Tactile 
fremitus is lost early. The motion of the affected side on respiration 
is almost nil, while the other side shows the usual expansion. The dull- 
ness caused by the effusion is only noted posteriorly in slight effusion, 
and rises higher there than in front. If not confined Ly adhesions the 
fluid changes with change of posture. If it ascends to the lower border 
of the third rib, the note is tympanitic above it (Skoda's resonance). In 
large exudations the cracked-pot sound may be found below the clavicle, 
and " Williams' tracheal tone" may be obtained. 

Auscultation reveals dry friction sounds in the first stage. When 
effusion occurs this is lost, the vesicular murmur weakens and even dis- 
appears, while if the lung is wholly compressed the bronchial sounds 
may be lost; if not, there is bronchovesicular breathing above the fluid. 
The vocal resonance may simulate the bleating of a goat (Laennec's 
egophony). 

During absorption the distention subsides, and respiratory move- 
ment returns. If the lung does not re-expand the intercostal and clavic- 
ular spaces sink, the ribs are drawn together, the spine curves laterally, 
the heart is drawn over, and this perhaps, with bronchiectasis and emphy- 
sema, fills up the vacuum. As the fluid recedes, if the lung expands 
the normal sounds gradually reappear, and displaced organs resume 
their proper locations. Friction sounds may remain for a long time. 
The lower part of the lung may remain compressed. 

Tubercular pleurisy may be acute, subacute or chronic; primary, or 
secondary to tubercle in the lungs, peritoneum or elsewhere. The effusion 
is often sanguineous. Recovery is possible. 



348 SEROUS PLEURISY 

Diaphragmatic pleurisy occurs with acute symptoms, moderate effu- 
sion, pain along the tenth rib, increased by deep inspiration and by pres- 
sure over the diaphragm into the tenth rib, dyspnea, cough, and nausea 
or vomiting. The fever is unusually high, the anxiety extreme. If the 
effusion is purulent the lower intercostals bulge, with edema later. 

Local pleurisy may occur with a moderate effusion, encysted by 
adhesions, in any part of the chest. The diagnosis may be assisted by 
aspirating. 

Interlobar pleurisy may cause encapsulated collections between the 
lobes. It is more frequent in the right lung between the upper and middle 
lobes. The ailment may be denoted by the appearance of pus in the 
sputa, the previous symptoms having been indeterminate. 

Hemorrhagic pleurisy occurs from the tubercular infection, cancer, 
nephritis, hepatic cirrhosis, septic debility, old age and alcoholism, and 
perhaps without detectable cause. 

Diagnosis: — Pneumonia begins with a chill, thoracic ache, rusty 
sputa (at first gray), intense fever, ending by crisis, marked prostration, 
flush on one cheek, herpes, pneumococcus in the sputa; signs of 
increased tactile fremitus, crepitus at first; imperfect dullness in 
second stage, bronchial breathing, bronchophony, and yields blood on 
aspiration. 

Pleurisy shows a less marked onset, stitch-pain, cough dry and repressed 
from pain, no pneumococci in sputa if any are raised, moderate fever, 
ending by lysis, some debility rather than prostration, face pale, no herpes, 
thorax distended on affected side, lessened tactile fremitus; dullness 
absolute over effusion, neighboring organs displaced, dullness may shift 
on change of posture, breath-sounds absent, vocal resonance less, egophony, 
friction sounds in first and third stages, aspiration yields serum. 

Tubercular consolidation has a different history, more fever, rapid 
decline, the tubercle bacilli in the sputa. 

Hydrothorax has the history and causes of dropsy, and the fluid shifts 
on change of posture; there is no fever, it is bilateral, no pain or friction- 
sounds. The specific gravity of the fluid is below 1015, that of pleurisy 
above 1017. 

Tumors distend the thorax partially, not beginning at the most depen- 
dent part, the tactile fremitus and vocal resonance are higher, the history 
differs, there are no friction-sounds except from accompanying pleurisy. 
Hepatic tumors, cysts or abscesses cause dullness, beginning below but 
at a limited point, and at all stages there is usually resonance on one or 
both sides, where in pleurisy there would be dullnesss. A puncture 
settles doubtful cases. 



SEROUS PLEURISY 349 

Pericardial effusions cause urgent dyspnea, with feeble heart-sounds, 
the heart is not displaced, the dullness is in front rather than behind, 
and the history of rheumatism may be had. The history may separate 
tuberculous from other forms of pleurisy, the serum may be examined 
for the bacillus and guinea-pigs inoculated with it. 

There is no definite course to a pleurisy. The inflammation may 
last one to three weeks. The effusion is usually absorbed fast or slowly, 
much as it was effused. Large effusions may persist or develop into 
empyema. The absence of bacteria indicates tuberculosis. The prog- 
nosis in simple serous cases is good. Death sometimes occurs from a 
sudden and copious effusion. 

Tredtment: — The management of this form of pleurisy is identical 
with that of the fibrinous form, during the first period. We have, how- 
ever, to deal here with a bulky effusion, which compresses the lung and 
may permanently destroy its power of expansion. The question arises, 
how to deal with this effusion. In some instances the compression has 
been relieved in a few days and yet the lung failed to unfold. In such 
cases it is probable that there has been an exudative inflammation in 
the carnefied lung-tissues permanently gluing them together. On the 
other hand, such profuse exudations have existed for many weeks and 
still the lung resumed its functions. 

Paracentesis thoracis is a simple and harmless operation when asepti- 
cally performed, and even in the febrile period, when the effusion is so 
bulky as to compress the lung into an airless mass, it seems wise to remove 
a portion of the fluid. In double pleurisy, or when respiration is ser- 
iously embarrassed, or signs of commencing hyperemia appear on the 
unaffected side, or when syncope, orthopnea, cyanosis or murmurs in 
the displaced heart occur, enough fluid should be withdrawn to give 
relief. No attempt should be made to withdraw all the effusion, as this 
would bring inflamed pleura together and increase the pain and fever. 

When the fever has subsided, the sooner the fluid is aspirated the 
better. No good object is obtained by its presence, and ftvery day the 
lung remains compressed adds to the danger of permanent disability. 
\\ hen a goodly portion has been removed and the pressure relieved, 
absorption usually sets in. If the lung does not at once expand some 
danger would ensue by removal of its support. The fluid should there- 
fore be allowed to drain away slowly and spontaneously, not solicited 
or forced. If dyspnea, incessant cough, sharp pain or a sense of oppres- 
sion occur, the needle must be at once withdrawn. 

The aspirator must be aseptic, the skin washed with soap, ether and 
bichloride solution 1 to 1000. Raise the arms so as to separate the ribs 



350 EMPYEMA 

and insert the needle close to the upper border of the rib. The best 
places are the sixth interspace on the right, the seventh on the left, under 
the middle of the axilla; or just below the outer angle of the scapula in 
the seventh right or eighth left spaces. If the pleura is very thick or a 
mass of lymph is struck the fluid may not be found at the first puncture. 
Larger needles are required as the fluid becomes thicker. From four 
to twenty-four ounces may be taken at one time, more during the febrile 
stages than later. Absorbent combinations should be employed to 
stimulate the removal of the effusion, with the dry diet. Iron iodide 
is often indicated by the presence of anemia, gr. 1-12 every two hours. 
In the young where lime is needed, calx iodata offers an admirable 
resource, gr, J every hour. 

EMPYEMA 

Sometimes the pleuritic exudate contains pus; similar to the ordinary 
pus unless pulmonary gangrene is present, when the fluid is exceedingly 
fetid. The inflammation is more intense than in common pleurisies, 
and the tissues are thickened, granular, perforated or eroded. The 
altered membranes consist of ' new connective tissues, bloodvessels and 
leucocytes. Empyema may follow ordinary pleurisy. In children it 
occurs early or from the first; it may be secondary to septic fevers, result 
from invasion of the pleura by cancer or tubercle, or follow penetrating 
wounds. The organisms most frequently met are micrococcus lanceola- 
tus, streptococcus, staphylococcus and tubercle bacillus. Pneumococcus 
cases are milder. Leptothrix occurs in putrid effusions. 

Symptoms: — There may be an acute onset, chills, fever, prostration, 
severe pain made worse by breathing or exercise. If gangrenous, the 
prostration soon becomes extreme and death occurs in a few weeks. Often 
the acute symptoms subside in a week and chronic symptoms arise. Dyspnea 
is apt to be more prominent than pain and cough; but the evidences 
of sepsis — irregular chills, fever and sweating, rapid wasting, etc. — soon 
predominate. Peptonuria is a diagnostic evidence of value, though 
simply indicative of suppuration, not excluding tubercle, etc. The 
same may be said of indicanuria. Leucocytosis is always present. 
It is especially in empyema that spinal curvature is likely to occur. 

The pus may discharge through the lung, causing pneumopyothorax; 
less often through the skin, esophagus, pericardium, stomach or peri- 
toneum. 

The signs are those of ordinary pleurisy. The chest-wall may become 
edematous, the pus pointing and discharging externally. The pus does 



CHRONIC PLEURISY 351 

not change level with posture as readily as a serous effusion. Baccelli's 
sign is the transmission of the whispered voice through a serous collection, 
not through pus. The cardiac pulsations are sometimes transmitted 
through empyema, rarely through a serofibrinous exudation. The 
necessary elements are a copious effusion, relaxed thoracic wall, and a 
strong heart-beat. It is usually on the left, front and side. 

Empyema is diagnosed from ordinary pleurisy by the rapid decline 
and other evidences of sepsis, and by the aspirator. Pulsating empyema 
does not appear in the location of aortic aneurism, there is neither heave 
nor bruit, and the constitutional symptoms differ totally. 

The prognosis depends first on the cause, second on the treatment, 
third on luck. Death may occur from the discharge of pus in a fatal 
way, from exhaustion, or from intercurrent or complicating disease. 
Children recover better than adults. Recovery occurs only with gradual 
adhesion of the pleura, obliterating the cavity, and subsequent retraction. 

Tredtment: — In children it may be allowed three weeks for nature to 
cure. In adults a large empyema should be aspirated at once. Follow- 
ing pneumonia, it is best to make a free incision and drain. Open in 
the fifth or sixth intercostal space, outside the nipple, the incision being 
an inch long. Estlander's rib resection is not necessary if free drainage 
can be secured without it. If the pus is offensive the cavity should be 
irrigated antiseptically; otherwise insert iodoform gauze. Expansion 
of the lung is favored by systematic exercise. James' method is to have 
the patient force water from one bottle to another by means of tubes, 
the effort being gradually increased. It is best to use boric acid, per- 
manganate or aromatic antiseptic solutions for irrigation, as bichloride, 
phenol and peroxide are unsafe. 

Every effort should be taken to keep up the strength, by rich feeding, 
etc. The arsenates of iron and quinine each gr. 1-6 and of strychnine 
gr. 1-30 should be given every two to four hours, with calcium sulphide 
gr. 1 seven times a day to restrain suppuration. Whether the latter 
would cure without operation I am not prepared to say, but it is the most 
effective antagonist of suppuration-germs yet produced. Nuclein solution 
should be given up to a dram daily. 

CHRONIC PLEURISY 

Chronic serous pleurisy may follow the acute form or develop insid- 
iously. There may be scarcely any symptoms except dyspnea on exer- 
tion, perhaps a sense of fullness in the chest, an occasional long-drawn 
inspiration. The pulse may be faster and slight evening fever be present, 



352 PNEUMOTHORAX 

with some fall in the patient's strength and in his weight. The malady 
may develop into empyema, especially in children. The affection runs 
on for months or years, and may end in tuberculosis. 

Chronic dry pleurisy may also follow the acute or chronic serous 
form. The fluid is absorbed rapidly at first, more slowly as it thickens, 
the pleura come together and adhere, forming a fibrous capsule com- 
pressing the lung. 

Some cases are dry from the start, and may present no symptoms 
of effusion. The pleura adhere, the respiratory motion is restricted, 
the sounds are weak, the other lung is hypertrophied, the heart displaced, 
spine curved, thorax distorted. Sometimes vasomotor equilibrium is 
disturbed, flushing or sweating unilaterally, or dilatation of the pupil, 
occurring. 

PLEURAL EFFUSION. 

History of pleurisy, 
Unilateral, 
Effusion following change of posture only at first, being soon en- 
cysted by adhesion of pleura. 
Fever, 
Heart displaced. 

' HYDROTHORAX. 

General dropsy, 

Bilateral, 

Fluid follows change of posture throughout. 

No inflammatory adhesion, 

No fever, 

Heart in normal position, but muffled by pericardial effusion. 

The treatment looks to removal of effusions if present and improve- 
ment of nutrition. Carefully regulated diet, gymnastics, the pulmonary 
and hygienic regime in general, and climatotherapy, are the leading 
indications. The tonics, digestives, reconstructives and absorbents, 
are required when indicated. Cases vary too much for a fixed line of 
treatment. The persistent action of arsenic, mercury and iron iodides, 
in moderate doses continued for many months, gradually brings about 
absorption of the effusion. Iron iodide, gr. 1-6, with gr. 1-67 each of 
the others, may be given three to seven times daily; the bowels and kidneys 
being kept in activity to stimulate the removal of the loosened debris. 

PNEUMOTHORAX 

If air be admitted to the pleura the lung collapses into a firm mass 
attached to the bronchus, the air fills the sac, obliterating the intercostal 
depressions and giving a clear, tympanic percussion note over the entire 



PNEUMOTHORAX 353 

side, with no respiratory sounds whatever. If the admitted air is sterile 
it is rapidly absorbed; if it carries the germs of suppuration pyopneu- 
mothorax develops. 

The causes of pneumothorax are: Perforation from a tuberculous 
cavity, gangrene, bronchopneumonia, glandular suppuration, abscess, 
cysts, rupture of air-cells by strain, perforating empyema, cancer or 
esophageal abscess, bronchiectasis, cancer or ulcer of stomach or colon. 
Gases may be developed in the pleura by certain organisms. Wounds 
may penetrate the pleura. 

The occurrence of pneumothorax is attended by sudden and intense 
dyspnea and pain, sometimes cyanosis, hurried breathing, the pulse weak 
and fast, cold sweat, and collapse, in which death may occur. The tem- 
perature falls below normal and then rapidly rises as pleurisy develops. 
It is usually hectic. As suppuration ensues edema of the hand on the 
affected side sometimes occurs, soon disappearing. As fluid collects in 
the pleura, when the patient shakes the chest splashing is heard, the "Hip- 
pocratic succussion," or "metallic tinkling," from drops falling into the 
fluid. "Wintrich's sign" is a change in the pitch of the percussion sound 
as the mouth is open or closed. The "coin-test" is considered pathog- 
nomonic. A coin is held on the front of the chest and tapped with anothei 
coin, while the examiner's ear is applied to the back of the thorax, when 
he hears the intensified echo of the sound produced. The cracked-pot 
sound and Wintrich's sign are more frequent in a large pulmonary cavity 
than in pneumothorax. The former does not dislocate the organs and 
has no response to the coin test or succussion. 

Gastric flatulence has been mistaken for pneumothorax. Sub- 
phrenic abscesses containing air occur, mostly on the right, from gastric 
ulcer. Diaphragmatic hernia results from injury or congenitally, and 
is recognized by its cause, rumbling, and possible reduction. Emphy- 
sema is slow in development and has none of the specific signs mentioned. 

The prognosis depends on the cause. 

Tredtment: — Combat shock and collapse with glonoin and atropine, 
gr. 1-250 each, every fifteen minutes till reaction occurs; relieve pain 
by morphine if necessary. Great dyspnea may indicate the wisdom of 
drawing off the air with an aspirator, but if the malady is due to a wound 
that is capable of healing it is better to leave the lung collapsed till this 
has taken place. In fact, Nuverricht in cases of pleural fistula inserts 
a tube to secure the free access of air until healing is complete. The ten- 
dency to suppuration calls for saturation with sulphides, while the vitality 
is sustained by full doses of nuclein and the tonic arsenates — iron, qui- 
nine and strychnine. Murphy's experiments have shown that sterile 



354 HYDRO THORAX 

gases are rapidly absorbed from the pieura. If suppuration occurs 
the treatment is that of empyema. 

HYDROTHORAX 

Hydrothorax signifies the presence of serum in the pleura, usually 
in both, and occurring in general dropsy, especially in hydremia. It 
also occurs in chronic diarrhea, dysentery, leukemia, pernicious anemia, 
cancer, malaria, syphilis, scurvy and compression of the thoracic duct. 

The symptoms are dyspnea, cyanosis, cough, weak heart, general 
debility, with dullness on percussion, the fluid shifting with change of 
posture. 

The treatment is that of the causal malady. Tapping is done as in 
serous pleurisy. 



PART V 



DISEASES OF THE CIRCULA 
TORY SYSTEM 

I. DISEASES OF THE PERICARDIUM 



ACUTE PERICARDITIS 

An3tomy: — The inflammation may be confined to a part of the serosa 
onJy, or affect the whole sac and extend into the myocardium or the fibrous 
layers beneath the parietal layer. The inflammatory process usually 
commences at the upper part, about the origin of the great arteries, as 
a dilatation of the serous capillaries and arterioles, with desquamation 
of the endothelium. The disease may stop here or proceed to exudation. 

In the fibrinous form the exudate occurs as a thin grayish or yellowish 
pellicle, loosely attached to the underlying surface. This becomes thicker, 
and more adhesive. The heart motions pulling this apart give rise to 
appearances known as cor hirsiitum, villosum and tomentosum; compared 
to the surfaces of two pieces of buttered bread or adhesive fly-paper pulled 
apart. Thicker and denser masses cause adhesions, known as recent 
by their color. This form is believed to be tuberculous in many instances 
(Osier). It may end in the chronic form. 

Fluid effusions may be serous, purulent or hemorrhagic. Serous 
effusions generally contain floating fibrin in large or minute masses, set- 
tling on the walls in creamy deposits. The presence of leucocytes or 
red blood elements gives rise to transition forms. Abundance of cells 
characterizes the purulent variety. Pus forming may burrow, and appear 
beneath the skin in the neck or in the first intercostal space on the right 
side. Sometimes the pus becomes sterile and undergoes calcification; 
more commonly it must be removed. 

The hemorrhagic form is perhaps most marked in scurvy, but is seen 
in cancer and in tuberculosis. Usually the quantity of the fluid is large, 
and the effusion may occur suddenly, causing acute anemia. 



356 ACUTE PERICARDITIS 

In the exudate have been found the pyogenic bacteria, the pneumococ- 
cus, and the tubercle bacillus. Putrefactive organisms cause fetor, the 
b. aerogenes capsulatus causes the evolution of gas. The presence of 
microorganisms can not always be demonstrated, but their absence is 
not thereby proved. 

Etiology: — Primary pericarditis occurs only from trauma (Babcock); 
secondary attacks being due to extension from neighboring organs, general 
diseases or hemic disorders. Flexner found the micrococcus lanceolatus 
most frequently and in eleven cases where this was detected, pneumonia was 
present in eight. Rudini attributed the disease to the staphylococcus a ureus. 

Pericarditis may occur in the course of many infectious maladies, 
without being recognized unless something arises to induce the physician 
to make a critical examination of the cardiac conditions. The resulting 
products may be observed. 

Rheumatism is the most common precedent of pericarditis. It is more 
apt to attend first attacks of rheumatism, the frequency depending largely 
on the treatment of the causal malady. Even mild forms are likely to 
be followed by pericarditis, in children; but the latter is infrequent if 
but one joint is affected. Babcock says it may appear at any time during 
the rheumatic attack, or even precede it, but generally the symptoms 
appear about the fifth day. Young adults are more frequently affected, 
especially if their occupation entails exposure. 

All forms of nephritis are attended by pericarditis, more frequently 
than is usually supposed, especially the contracted kidney, and cases 
where uremia occurs. 

Acute pneumonia was accompanied by pericarditis in 92.4 per cent 
of 79 fatal cases seen by Preble. Pericarditis has also been noted during 
the course of or subsequent to attacks of scarlatina; and in connection 
with erysipelas, variola, typhoid fever, measles, cholera and diphtheria. 
To this list Flexner adds bronchitis, leg ulcer, sloughing myoma, gastric 
cancer, tonsillitis and peritonitis. Mediastinal tumors, bronchial adenitis, 
abscesses, costal caries, empyemas rupturing into the sac, perforating 
esophageal or gastric ulcers, and intraperitoneal abscesses, are sometimes 
attended by pericarditis, usually purulent. Acute inflammation may 
be caused by aortic aneurism, while tubercle usually occasions more 
chronic forms. 

The hemorrhagic variety occurs secondarily to scurvy, purpura or 
hemophilia; possibly in tuberculosis or cancer. Old age and alcoholism 
also favor this form. Traumatic cases are not necessarily accompanied 
by perforation of the pericardial sac. Chronic valvular heart diseases 
predispose to pericarditis, especially aortic leaks. 



FIBRINOUS PERICARDITIS 357 

FIBRINOUS PERICARDITIS 

Symptoms: — The invasion and even the existence of this affection are 
apt to be masked by the symptoms of the original malady The peri- 
carditis may be unsuspected, or latent. But a sudden rise of fever, or 
the development of delirium and nervous crises, without apparent cause, 
in the primary malady's course, should direct attention to the heart, 
especially in children suffering with rheumatism. 

Pain, or a sense of distress, occurs early, in the cardiac region or 
pigastrium, sometimes radiating over the chest or to the left arm. If the 
posterior portion of the area is affected the pain may be felt between the 
shoulders. Pain and tenderness have been noted along the larynx. Cuta- 
neous hyperesthesia may hinder percussion. Dysphagia may be present, 
and pain with each pulsation. The pain may be sharp or dull, continuous 
or intermittent, it is worse in neurotics, and subsides when effusion 
occurs. 

In some cases a dry, irritative cough is present, resembling that of 
pleurisy. The pulse is fast, soft and regular in the early stages. Respira- 
tion may be rapid and shallow, repressed as in pleurisy. The fever does 
not exceed 103; continuous or remittent. Supervening upon chronic 
renal or cardiac maladies, not rheumatic, fever is slight or wanting. Its 
duration varies but may average 18 days. 

Anorexia, constipation and flatulence are generally present, as well 
as scanty high-colored urine, disturbed sleep, restlessness and facies 
indicative of suffering in children. With them also we are apt to have 
marked nervous phenomena, twitching, restlessness, subsultus, low 
delirium and excitement. Dyspnea is not prominent until the effusion 
embarrasses the heart and lungs, unless endocarditis accompanies, when 
this symptom occurs earlier. 

The foregoing assemblage of symptoms has been compiled from many 
cases and probably no one case ever presented all of them. In fact, there 
may be so little indication of the malady that in rheumatism and other 
affections liable to pericardial complication it is wise to examine the heart 
carefully at every visit. 

Partial pericardites may run their course to recovery within a week. 
Severer forms run for some weeks, and may end in death, especially in 
case of children with preexisting cardiac lesions, or in recovery with 
permanent injury to the pericardium. The heart may dilate, especially 
with children, or the inflammation may extend to the heart muscle, 
involving peril. Thick deposits of fibrin on the heart may seriously inter- 
fere with its function and with nutrition. 



358 FIBRINOUS PERICARDITIS 

Diagnosis: — Inspection may reveal an anxious expression, disturbed 
respiration and heart-action, but these have little significance unless as 
pointing to coexistent disease. Palpation may detect fremitus in the 
second or third intercostal space to the left of the sternum. This is not 
frequent. The peculiar gliding character of the friction-fremitus 
ditnguishes it from an endocardial thrill (Babcock). Moderate pressure 
may increase, forcible pressure lessen or efface it. 

Auscultation reveals friction sounds early. This may be heard in 
the second, third or fourth intercostal space at the left sternal margin; 
sometimes over the apex, or even over the whole cardiac region. It is 
not synchronous with systole or diastole or with either heart sound, but 
may accompany, precede or follow them. The rhythm of each case is 
peculiar and uniform to it. The to-and-fro rhythm resembles a double 
aortic bruit but is not identical with it. This peculiarity is due to the 
variations in friction during the auricular and ventricular systole and 
diastole, presenting varying conditions. The shorter first part occurs 
during the auricular systole, the two longer during the ventricular systole 
and diastole. Endocardial murmurs are not affected by pressure as 
exocardial murmurs. This sound may disappear temporarily. Its 
nature depends on the nature of the exudate and the strength of the heart 
contractions; its quality on the consistence of the fibrin — creaking, crack- 
ling, usually a soft brushing. It is apt to be louder when the patient 
is erect but the reverse may happen. Forced inspiration may make the 
sound louder — or the reverse. The heart sounds are not affected by 
pericarditis alone. 

Pressure affects the friction sound as it does the fremitus. 

The diagnosis is usually simple, the disease being readily recognizable 
when attention has been called to it, by the preexistent disease and pain 
about the heart; the characteristic rubbing, thrill and murmur confirm 
the suspicion. 

Endocarditis can with difficulty be excluded unless valvular murmurs 
are present, and the effects of pressure on the fremitus and the friction 
murmur are evident. In pleurisy the friction sound ceases when 
respiration is suspended. It must not be forgotten that pleurisy may 
coexist. Pneumonia presents the initial chill, high continued fever, 
cough, rusty sputa, crepitation, dullness, bronchial breathing, alteration 
of the ratio between pulse and respiration, and the characteristic course. 
Babcock describes two cases in which aortic aneurisms were taken for 
pericarditis until the subsequent course corrected the diagnosis. 

Prognosis: — This is serious in children with rheumatism. Extension 
to the heart muscle may be inferred when the pulse becomes thready and 



PERICARDITIS WITH EFFUSION 359 

intermits, the first sound at the mitral is feeble and muffled, the second 
aortic sound diminished. It is a condition of great danger. Serious 
implication of the nervous system is a grave indication. Even when 
recovery from the acute attack occurs, adhesions may be left which will 
lead to future difficulty. The plastic exudation is rarely absorbed. Occur- 
ring with endocarditis, pleurisy, pneumonia or chronic nephritis, the 
prognosis is graver than in rheumatic forms. 

PERICARDITIS WITH EFFUSION 

A variable proportion of fibrin is always present in the serous effusion 
and when the first exudation is plastic a large serous effusion may occur 
later. The quantity varies from a few drams to a quart or more. It 
may occur gradually or distend the sac within twenty-four hours. In 
the purulent form we find pus with little fibrin but various bacterial 
elements. In the hemorrhagic form, blood may be present in the primary 
effusion or it may appear later in a serofibrinous fluid. These effusions 
simply indicate varying grades of the disease. 

Symptoms: — The effusion collects in the lowest portion of the sac, 
and as in pleurisy by stopping the friction of the inflamed surfaces puts 
an end to the pain. The fever and cough, however, continue. As the 
exudation relieves the pain, it gives rise to symptoms due to pressure on 
the neighboring organs. Yet there is not always a direct relation between 
the bulk of the effusion and the severity of the pressure effects. Children 
are less apt to complain of these but rather display restlessness and other 
nervous phenomena. The face may be pallid or bluish white, the jugu- 
lars turgid, the pulse weak, rapid and soft. Its rhythm may be irregu- 
lar, and in the later stages this indicates grave implication of the heart 
muscle. Pressure upon the heart causes general disturbance of the 
circulation. The auricles yield to the pressure more readily than the 
ventricles, and the supply of blood to the heart is obstructed. The left 
lung is compressed, giving rise to dyspnea; and, if the pressure be very 
great, to cyanosis. This, with the cerebral venous congestion, seriously 
interferes with sleep. The appetite is destroyed and swallowing may 
cause severe pain. The urine is scanty. Tympanites adds to the dyspnea. 
The liver is passively congested and tender. Constipation exists at first 
until the engorgement of the intestines causes serous diarrhea. If pro- 
tracted, dropsy of the limbs follows. 

The fever varies widely, but sinks when effusion occurs. Pressure 
symptoms occur more decidedly when the effusion rapidly distends the 
sac. If the effusion is purulent, the symptoms vary with the micro- 



360 PERICARDITIS WITH EFFUSION 

organ isms present. The distention is then usually very great. Septic symp- 
toms occur, such as chills, sweating and fever of the hectic type, septice- 
mia being most marked when the pus is fetid; prostration then occurs 
early and is extreme. 

Hemorrhagic effusions also occasion most distress when rapidly poured 
out. 

There is no typical course to this form of pericarditis. Rheumatic 
cases may end within a week or be protracted to a month, or even become 
chronic. Improvement may be followed by relapses until the patient 
is worn out. The course is greatly modified by the original disease. 
Occurring with renal disease, the course is apt to be slow and latent: 

Occurring in rheumatic children, permanent cardiac disease remains. 
Purulent forms rarely tend to resolution, the patients dying sooner or 
later from septicemia. The scorbutic form often proves fatal in one or 
two days. Some times the exudation is completely absorbed, leaving 
the patient in excellent health. 

Diagnosis: — The effusion may be evident on inspection, in young 
patients with yielding thorax, or the intercostal spaces may bulge. The 
apex beat disappears, the ventricular impulse is diffused or absent, or 
it may be lower than normal. The pressure effects are evident. 

Fremitus ceases when the sac is distended. Palpation may show 
increased internal thoracic tension. Fluctuation is rare. Ewart found 
in some cases the head of the left clavicle so elevated that the first rib 
could be felt up to the sternum. The pulse is rapid, may be arrhymthic, 
or pulsus paradoxus, the tension markedly low. 

Percussion is the most reliable means of diagnosis, as by it very small 
quantities of effusion may be recognized. The dullness forms an irregu- 
larly triangular area with the apex about the first intercostal space to the 
left of the sternum. The lower margin may reach the seventh intercostal 
space. To the left it extends beyond the apex beat, which distinguishes 
pericardial effusion from enlargement of the heart. In pericardial effusion 
the line of demarcation between the effusion and the lung is much more 
abrupt than it is in dilatation of the heart, unless the lung overlaps the 
distended sac. Rotch's sign is the development of a small triangle of dull- 
ness in the fifth right intercostal space when the effusion first takes 

The friction sound disappears when effusion occurs, and reappears 
as absorption permits the inflamed surfaces to again come in contact. 
However, the friction sound may persist even with a large effusion. The 
heart sounds are muffled and may be almost inaudible, especially the 
sounds at the apex. The pulmonic second sound is accentuated, the 
aortic diminished in proportion as the venous congestion increases. 



PERICARDITIS WITH EFFUSION 361 

Compression of the lung causes a loss of the normal resonance. Below 
the left clavicle percussion elicits Skoda ic resonance. Pins' sign is dull- 
ness and bronchial breathing below the left scapula. When the patient 
leans forwards, this gives way to tympanitic resonance and crepitation 
followed by vesicular respiration. Ewart found dullness in extensive 
effusions posteriorly from the spine to the internal border of the scapula. 
At this place the respiratory sounds are absent, the voice sounds feeble. 

When the effusion is free, the diagnosis is easy. It is, however, 
more difficult to determine the nature of the effusion. In rheumatism 
it is usually serofibrinous; in septicemia, empyema, gastric ulcer or per- 
forating wounds, it is generally purulent. Septic symptoms indicate 
the presence of pus. An effusion rapidly developing in scurvy, purpura 
or cancer, with quickly supervening anemia, indicates hemorrhage. The 
diagnosis, however, usually requires a puncture. Emphysema with 
adhesions may mask the area of dullness, or force the effusion into 
unusual situations. If this is confined to the posterior part of the sac, diag- 
nosis is difficult. We then have evidences of inflammation, with pressure 
on the esophagus and bronchi, causing difficulty of swallowing and breath- 
ing. Dilatation of the heart with retraction of the lung presents a dull 
area resembling that of effusion, and if fatty degeneration weaken the 
impulse, the diagnosis may be impossible. The main point is that in 
dilatation the apex beat corresponds with the outer lower margin of dull- 
ness, while in effusion the dullness extends beyond the apex beat. This 
may be distinguished better when the patient sits up than when he is 
lying down. If the diagnosis cannot otherwise be made, heart-tonics 
like digitalin may strengthen a weak heart, restoring the apex beat and 
heart-sounds, or if the case be one of pericarditis, cause absorption of 
the fluid and return of the friction sound. 

There is some similarity in the symptoms of pleurisy, but the area 
of dullness is different. Left pleurisy displaces the heart to the right; 
vesicular sounds are absent. Pleurisy rarely, if ever, causes dysphagia 
and generally the presence of the antecedent disease directs attention 
to pericarditis. The history and physical examination may be depended 
upon to exclude mediastinal tumors and localized tubercle or pleuritic 
adhesions. 

Prognosis: — Purulent forms are dangerous unless early diagnosed 
and effectively treated. Hemorrhagic forms rapidly prove fatal if acute; 
if chronic, the results depend on the primary disease. Rapid large 
effusions are always dangerous. Inflammation of the myocardia or 
degeneration adds seriously to the peril. Pressure or disease seriously 
embarrassing the heart or the lungs is of grave omen. Accompanying 



362 PERICARDITIS WITH EFFUSION 

endocarditis or preexistent valvular disease increases the gravity. The 
same may be said of nephritis, pulmonary tuberculosis, or other incur- 
able chronic diseases. Occurring with rheumatism in young children, 
permanent disease of the heart is very probable. Aged and cachectic 
patients usually succumb. Even when recovery from the acute disease 
takes place, there may remain a myocarditis or obliteration of the sac. 

TreBtment: — It is evident from the serious prognosis of pericarditis 
that it is of the first importance to prevent the supervention of this dis- 
ease. This renders it necessary that the physician should appreciate 
the possibility of its occurring in other maladies as well as in rheumatism. 
The prompt and effective treatment of rheumatism, however, is the most 
important point in the prophylaxis. Physicians as a rule fail to appre- 
ciate the importance of protecting their patients, with infectious diseases, 
from exposure to draught. 

For the treatment of rheumatism and other infections causative of 
pericarditis, we refer the reader to the chapters on those topics. The 
patient must be kept quiet and in the recumbent posture; even the exer- 
tion of rising to a sitting position increases the work of the heart and also 
the inflammation. Babcock prefers the application of cold. We are 
well aware that we stamp ourselves as heretics by affirming our sincere 
belief that the mercurials are of greater benefit than the application of 
cold. Counterirritants, however, often relieve the pain and when this 
is the case they are certainly preferable to opiates. Weighty applica- 
tions are obviously to be avoided. The bowels should be promptly and 
thoroughly emptied. Give gr. 1-6 of calomel every half hour for six 
doses, followed by a dose of ' saline laxative, and repeat one or 
both as often as may be necessary. Fecal toxemia most assuredly does 
not lessen the sufferings or the peril of the patient. Elimination may 
be increased by the administration of veratrine, gr 1-134, every two to 
three hours. We are not disposed to accept the orthodox dictum as to 
the impossibility of influencing the inflammatory process; and we would 
advise therefore, the administration of mercury biniodide gr. 1-67 
and calx iodata gr. J together, every hour, until evidences of iodism 
are manifested. It has not yet been proved that mercury and iodine 
do not check the tendency to plastic exudation and hasten the absorption 
of that already effused. If the disease is suppurative, we may add to 
the above the use of calx sulphurata, giving 1-2 gr. every hour, until 
saturation; then enough to sustain this effect. Even though the disease 
be due to microorganisms, the remedies whose good effects were explained 
by the old antiphlogistic doctrine may still be given with benefit though 
the explanation of their action then offered is now no longer accepted. 



PERICARDITIS WITH EFFUSION 363 

Pain and restlessness may require the administration of codeine, 
cannabis or iodoform, in doses sufficient to accomplish the purpose. 
Sleep may be secured by the use of one of the above or by grain doses 
of camphor monobromide, repeated ever hour. The cough is, we think, 
better relieved by the application of mustard over the pneumogastric 
nerve than by the use of any drug sedatives. Of the latter, zinc cyanide 
is better than any opiate; gr. 1-6 of this may be given every half-hour 
if necessary, and this will soothe restlessness and irritation much better 
than any drug which locks up the eliminants. The dosage should be so 
arranged as to secure the desired effect without weakening the heart. 
Nausea also is best relieved by counterirritation over the pneumogastric 
nerve; if indeed nausea be possible after the alimentary canal has been 
completely unloaded, and elimination is free. The fever may require 
a few granules of aconitine. For rapid violent heart-action in the early 
stage, Babcock prefers the ice-bag over the heart, but again we say that 
such a condition can scarcely occur with the alimentary canal and the 
eliminants properly attended to. Digitalin is not indicated unless the 
weak rapid pulse, of low tension, with comparatively empty arteries and 
engorged veins, indicate the wisdom of strengthening the heart and at 
the same time checking the escape of blood from the arterioles into the 
capillaries. Very small doses (gr. 1-67) should be given and carefully 
repeated at hourly or half-hourly intervals, until the desirable effect is 
manifested. The only preparation for such delicate dosage is obviously 
the Germanic digitalin, which is soluble in water and manifests its effects 
within half an hour, or sooner if administered in a little hot water and 
absorbed from the mouth instead of the stomach. Strychnine is usually 
indicated from the first; the arsenate being preferred as it is desirable 
to induce degeneration of the exudate as speedily as possible. The doses 
must be small, gr. 1-134 every hour being usually sufficient. The 
food should consist of raw eggs, milk and fruit juices, in quantity not 
exceeding four ounces, but repeated every four hours, with a small cup of 
coffee between the feedings. But little water should be given in addi- 
tion to what is contained in the food. Should distress follow the adminis- 
tration of food, or of the eight ounces of water required for the saline, 
the bowels should be emptied by small enemas of glycerin, or of saturated 
salt solution, and the food thrown into the colon. 

When the fever subsides and the exudation appears, the indications 
are changed. Supporting remedies are still more imperatively required; 
but the antipyretics may be laid aside for absorbents. The most power- 
ful absorbent combination known to the writer consists of the following: 
Mercury biniodide gr. 3-67; arsenic iodide gr. 1-67; iodoform and 



364 CHRONIC PERICARDITIS 

phytolaccin, of each gr. 1-2; the whole to be given four times a day. 
The ointment of mercury biniodide should still be applied over the heart. 
If the dyspnea and pressure symptoms are imperative, the fluid may be 
removed by tapping. Absolute rest is still more imperatively demanded 
than at the first. If the urine becomes scanty, more digitalin is needed 
or normal saline solution thrown into the colon. The congestion of the 
liver is best relieved by the saturated salt enemas mentioned. The point 
usually selected for puncture is the fifth left intercostal space, close to 
the sternum, or an inch or more from the bone to avoid the internal mam- 
mary artery. Purulent effusions should be removed by surgical methods. 
The remedies advised are not all needed at once but to be given alone 
or combined as may be indicated. 

CHRONIC PERICARDITIS 

Chronic pericarditis may involve the serous layer alone or may extend 
to the mediastinum; quite rarely the sac is distended with fluid. The 
first form, as adherent pericardium, is more frequently found in the dis- 
secting room than in the clinical amphitheater. 

Anatomy: — The chronic malady follows the acute form, the fibrinous 
exudate becoming organized. Granulation tissue forms, and is developed 
into fibrous cicatricial tissue. The two layers may adhere o\er a portion 
or all the pericardial surface; this being more common at the base of the 
heart. If adhesion does not occur the remains of the disease are shown 
by white patches, milk-spots or maculce tendinece. The thickening is 
generally marked, especially in tuberculous cases. Calcification some- 
times follows purulent exudations, leaving lime in plates or a complete 
covering over the heart, whose motion is permitted by cracks and fissures 
in this coat. 

Endocarditis and valvular disease may coexist, or the pericardial 
malady may occasion hypertrophy and dilatation, with the usual degen- 
erative sequences. 

The inflammatory process extending to the mediastinal tissues gives 
rise to induration, the connective becoming hyperplastic, and adhesions 
forming between the pericardium and the diaphragm, pleurae, esophagus, 
spine or the anterior wall of the thorax. Cicatricial contraction may 
lessen the lumen of the superior vena cava, aorta or pulmonary vessels, 
or the esophagus. The effects extend far beyond the heart, the inter- 
ference with the circulation causing disease in the lungs and other organs. 

The form in which effusion is found may follow repeated acute attacks, 
or show the tendency to the chronic type from the beginning. In the 



CHRONIC PERICARDITIS 365 

former the quantity of effusion fluctuates, in the latter it slowly increases. 
This form is more frequently met in aged persons, and with chronic 
nephritis. 

Etiology: — Rheumatism and the tubercle bacillus are responsible 
for most cases, some following any of the other causal conditions of the 
acute form. It rarely arises after the 30th year, has been found post 
mortem in infants, and males are much more frequently affected. 

Symptoms: — Many cases run a latent course and are never suspected ; 
others are confused with accompanying diseases. The pericardial com- 
plication in valvular affections may prevent compensation or cause its 
early failure. 

When there is no valvular disease present we may have palpitation, 
dyspnea increased by exertion, fast pulse, strong apex beat, cardiac 
enlargement; or the digestive disturbances due to venous stasis. The liver 
is enlarged, and cases presenting this feature are said by Babcock 
to be particularly resistant to treatment. Hemoptysis results from pul- 
monary engorgement, and edema may occur in the pulmonary tract. 
When the cirrhotic liver contracts, jaundice may appear, with ascites 
but no dropsy of the legs. 

Course: — The course is variable. If the disease stops with permanent 
adhesion, this remains during life. Mediastinal implication eventually 
brings about a fatal ending. 

Physical Signs: — If the adhesions are confined to the heart, there may 
be no signs discoverable. In mediastinal cases the adhesions alter the 
form and position of the heart, w T hich pulls on the parts on which it is 
adherent, causing retraction of the chest-wall during systole. This is 
best seen while standing behind the patient and looking down at the chest, 
the patient holding his breath for the moment. Broadbent's sign is 
systolic retraction of the tenth and eleventh intercostal spaces below the 
inferior angle of the left scapula. An important indication is fixation of 
theapex, the beat of which does not alter its position with change of posture. 
Kussmaul's sign is swelling of the veins during inspiration; Friedreich's 
sign collapse of the veins during diastole. 

On placing the hand over the apex a sudden shock is felt with the 
diastole. Palpation may also reveal the pulsus paradoxus, strong inspira- 
tion lessening the force and volume of the pulse or causing it to intermit, 
the usual strength and fullness being regained towards the close of expira- 
tion. Palpation may also determine fixation of the apex, and the condition 
of the liver. Percussion determines the degree of heart enlargement 
present. The increase of the dull area upward and to the left is significant. 
Fine friction sounds may be present at the edges of the dull area, persisting 



366 HYDROPERICARDIUM 

while respiration is suspended. Perez' sign is a creaking heard over the 
body of the sternum when the arms are raised and lowered. 

Diagnosis: — If no adhesions exist, we rely on percussion and a careful 
study of the circulation. In mediastinal cases, the signs described usually 
suffice. We may suspect pericardial adhesion in all cases of rheumatic 
valvular disease, especially if the liver is firmer and not smaller than in 
health; or if ascites develop without alcoholism. In Laennec's cirrhosis 
there is a history of alcohol, malaria or syphilis; in pericarditis, the history 
of the casual malady, and of acute pericarditis. In the former ascites 
develops before anasarca; in this edema may come first. No heart disease 
exists in Laennec's cirrhosis, nor are there signs of adhesion of the heart. 

When the sac is distended by fluid, we find evidences of the pressure 
exerted, unless the effusion has occurred latently : Here we must depend 
upon the physical signs. 

Prognosis: — Adhesion occurring alone, if it does not seriously interfere 
with heart-action, need not shorten life. Occurring with chronic valvular 
disease the prognosis is rendered worse. General adhesion must interfere 
seriously with circulation. Mediastinal disease tends to spread. Dropsy 
usually indicates the nearness of death. Venous engorgement is unfavor- 
able as are hypertrophy and dilation when marked. 

Treatment: — Intercurrent rheumatism or other disease must be promptly 
and effectively treated. Apart from this the indication is to delay the 
progress of the malady, especially as regards the trophic changes in the 
heart. The patient must be taught to live under the rule of his physician. 
The management of a lame heart will be so fully considered under the 
head of valvular disease that we will not repeat it here. Portal congestion 
requires care in arranging the diet, and periodic catharsis. Possibly some 
part of the organized fibrinous deposit may be removable by the continued 
administration of thiosinamin. One grain of this may be given three or 
more times a day for months. Heart tonics and other remedies should 
only be given when specially indicated. 

HYDROPERICARDIUM 

This term designates the effusion of serum into the pericardium, not 
from inflammation but as a part of general dropsy. The serous surfaces 
may be edematous or unchanged. The quantity effused may reach several 
pints. 

Etiology: — The cause is that of general dropsy. Occasionally loca 
conditions may be present, such as thoracic tumors compressing the veins. 
It may occur suddenly in scarlatinal or chronic nephritis. 



HEMOPERICARDIUM 367 

Symptoms: — We usually have accompanying effusions in the pleura 
and general dropsy. Respiration is embarrassed and the circulation 
may be impeded by any local cause of the dropsy, or by the distention of 
the sac; dyspnea may be extreme, the veins engorged, the arteries contain 
little blood, the pulse weak, rapid, irregular and of low tension. Cyanosis 
is usual. An effusion rapidly poured out causes more distress than one 
occurring latently. 

Physical Signs: — Inspection may reveal evidences of local obstructive 
disease with prominence of the cardiac region, the apex beat absent. Pal- 
pation shows absence of the cardiac impulse, and possibly, some disten- 
tion; percussion reveals the characteristic triangular dull area but the 
margins are lost in the pleural dullness, except at the apex under the 
manubrium. Auscultation shows the heart sounds weak, muffled or 
inaudible. 

Diagnosis: — This may be simply inferential unless the pleural effusion 
is first removed, when it is self-evident 

Prognosis: — The incurability of the causal disease, and the fact that 
hydropericardium occurs in the later stages, indicate the seriousness of the 
prognosis. 

The treatment is that of the primary disorder; tapping being rarely 
justifiable. 

HEMOPERICARDIUM 

f 

Rarely, blood is effused into the pericardium independently of inflam- 
mation, distending the sac according to the quantity effused. Rapid 
hemorrhages are smaller because the patient dies speedily. If death is 
delayed, the blood coagulates. The hemorrhage may occur from injury, 
rupture of the heart, aneurism, or a coronary artery. Wounds may occur 
from without, from crushing injuries to the chest or from a fractured rib. 
If the hemorrhage occurs slowly from a small wound, symptoms gradually 
supervene of heart- weakness with anemia, a sense of oppression, anxiety, 
prostration, dyspnea, pallor, cyanosis, cold extremities and clammy sweating. 
The pulse is weak, rapid and irregular. If the hemorrhage be free, the 
symptoms are of sudden shock, the patient dying speedily in collapse. 
The more rapidly the blood is effused the quicker death supervenes. 
Physical signs show the presence of blood in the pericardium. Diag- 
nosis is only possible when the hemorrhage occurs very slowly. We have 
then the indication of the causal disease or injury, the sudden development 
of the malady, with evidences of hemorrhage, shock and collapse. 

In traumatic cases the prognosis depends on the injury. The treatment 
is usually surgical. Sometimes it has been possible to lay open the sac, 



368 PNEUMOPERICARDIUM 

find and close the bleeding artery. Medical treatment can only be appli- 
cable in the rarest of instances. Naturally it should consist in the adminis- 
tration of glonoin for cerebral anemia, atropine to divert the blood to 
the surface and away from the bleeding orifice, and strychnine to sustain 
the vital forces. In some cases the intelligent use of these remedies may 
give time for surgery to save life. 

PNEUMOPERICARDIUM 

In extremely rare instances, gas has been found in the pericardium, 
usually with pus. The gas may enter through an orifice, or be formed in 
the sac. It may come from outside the body, the digestive canal, or 
the lungs. Gastric ulcers occasionally open the pericardium. The 
symptoms are those resulting from sudden distention of the sac. There 
may be shock, pallor and profound depression. Percussion shows the 
cardiac dullness replaced by tympanitic resonance. If fluid is present 
we have dullness in the dependent portion and tympanites above it, the 
two altering their location with changes of posture. Auscultation reveals 
splashing sounds^ sometimes metallic tinkling. 

The prognosis is serious but not hopeless when surgical intervention 
is applicable. If the sac is not infected, the gas may be absorbed. Sudden 
distention may cause fatal shock. The treatment consists in combating 
shock by the administration of glonoin, atropine and strychnine in full 
doses, hypodermically, or else absorbed from the mouth. Heat should 
be applied externally, Further than this the treatment is strictly surgical. 

PERICARDIAL TUBERCULOSIS 

The acute form resembles ordinary acute pericarditis, and can only 
be distinguished by the microscope. The effusion has, however, a greater 
tendency to be hemorrhagic. Caseation is common, calcification rare. 
Acute cases may terminate in the chronic form or the disease may be 
chronic from the outset. The attack may be primary or secondary to 
tuberculous developments elsewhere, especially in the bronchial or anterior 
mediastinal glands. The affection is most common between the ages of 
fifteen and thirty, the range, however, being as wide as human life. 

Tubercular pericarditis is generally latent. If it causes acute inflam- 
mation, the symptoms are those already described, pain, fever, palpitation, 
friction and the effects of pressure. There is nothing distinctive of this 
form in the physical signs. The diagnosis may be inferred from the 
existence of tubercle elsewhere. The prognosis is not very serious, yet 



ACUTE ENDOCARDITIS 369 

the affection is one more burden for the patient to sustain. The treatment 
is that of tuberculosis in general, and of pericarditis in particular. 

Pericardial Syphilis: — This malady is excessively rare, but tertiary 
orms have been described. When it does occur it accompanies syphilis 
of the cardiac muscle. The disease is limited to the cardiac layer and 
appears as gummata or indurations, the latter more common. The 
muscular tissue underneath is likewise affected. The morbid process 
ends in the formation of cicatricial tissue; adhesion sometimes occurs. 
The malady runs a chronic course. The symptoms are obscured by 
those of syphilis in the heart muscle or elsewhere. Very rarely a fric- 
tion sound may be detected, or the sac becomes distended with effu- 
sion. The diagnosis can scarcely be made during life; the prognosis 
is good; the treatment, that of syphilis. 

Pericardial Cancer: — Primary cases are extremely rare; secondary in- 
vasions occur in cancer of the mediastinum, stomach or esophagus. Either 
carcinoma or sarcoma may occur. Some effusion is always to be found 
in the sac, especially hemorrhagic. The symptoms are — those of the 
primary growth. There is nothing distinctive in the physical signs, and 
the diagnosis is rarely possible. The treatment is that of cancer. 



II. DISEASES OF THE HEART 



ACUTE ENDOCARDITIS 

Two forms of this disease are described, the simple and the malignant. 
The endocardium may become inflamed during fetal life, the right heart 
being then affected. After birth the attack is usually on the left side. 

The attack commences with cloudiness of the membrane, on which a 
swarm of micro-organisms has doubtless settled. The disease generally 
begins on the valves, especially the mitral, at the margins. The membrane 
becomes thickened, with serous infiltration, erosions or lacerations. These 
are usually at once covered by a deposit of fibrin from the blood, which 
projects above the surface forming vegetations. Under this the process 
of repair goes on, the endothelium is reproduced; the fibrinous deposit 
continues and forms warty or polypoid growths. These may be re-dissolved 
by the blood, or broken off and be carried into the current until arrested 
as emboli. 

The malignant or ulcerating form is due to more intense infection. 
It may result in vegetations, suppuration or ulcer. The destruction of 



370 ACUTE ENDOCARDITIS 

tissue is much greater than in the simple form. If emboli are carried into 
the blood they give rise to septic processes where they lodge. Valvular 
aneurisms or perforations may form, with consequent leakage. Ulceration 
may extend to the papillary muscles; perforation may unite several of 
the heart cavities or the right auricle and the aorta. If abscess forms 
in the heart-muscle the contents are discharged into the circulation. The 
simple form is frequently unnoticed, until after the lapse of years when the 
lesions it produces give rise to further changes. 

Etiology 7— Both forms are bacterial; malignant endocarditis being 
usually secondary to infectious disease elsewhere. The streptococcus 
pyogenes of erysipelas is common; also staphylococci pyogenes aureus and 
albus, micrococcus lanceolatus, gonococcus, and the bacilli of typhoid 
fever, diphtheria, influenza and tubercle. Several bacteria have only 
been found in endocarditis. Malignancy may be determined by the viru- 
lence of the microbes, their excessive number, or the low resisting power 
of the patient. 

The simple form most frequently follows rheumatism, of which it may 
be the first manifestation. It is especially apt to occur with a first attack, 
if severe and multiple, in young patients. The causal influence of chorea 
is generally admitted; but whether this is the case when rheumatism is 
absent, is still questioned. The erruptive diseases and typhoid fever 
give rise especially to the malignant form, as also does gonorrhea. Either 
form may accompany pneumonia. Septic infections favor the occurrence 
of the malignant form and tonsillitis or a boil has been followed by this 
affection. It has been attributed to gallstones, cancer of the pylorus, 
diphtheria, rheumatism and pneumonia. 

Symptoms: — Occurring in rheumatism, simple endocarditis may only 
be recognized years afterwards, when chronic valvular disease has reached 
a troublesome stage. But sometimes during an attack of rheumatism 
a rise of fever occurs without the involvement of a newly-afTected joint, 
or there may be pain about the heart, oppression or discomfort, palpi- 
tation, and especially a subjective sense of dyspnea, sometimes termed 
"air hunger." The dyspnea may be continuous or paroxysmal. Some- 
times there is marked general disturbance, fever alternating with per- 
spiration, the pulse irregular and disturbed, indicating a disease on the 
border between the simple and malignant forms. If embolism occurs 
the symptoms are those of infarction of the kidney, bowel or brain. If 
small the symptoms may be unnoticed; or they cause sudden sharp pains, 
chill followed by fever, and disturbance where the embolus lodges. If 
in the kidney the urine may contain blood, albumin or pus. In the brain 
they cause corresponding paralysis* 



ACUTE ENDOCARDITIS 371 

The course varies with the intensity of the infection. The simple 
rheumatic form may end in complete recovery, but usually some per- 
manent impairment of the valve results. 

Ulcerative Endocarditis:— We have here to deal with an inflamma- 
tion presenting symptoms of general sepsis, usually ending in death. 
The general symptoms may predominate, such as the fever of pyemia, 
slight rigors, profuse sweating, profound and rapid prostration, anemia, 
emaciation, anorexia, diarrhea, the tongue brown and dry, tympanites, 
stupor or low delirium, and enlargement of the spleen. The pulse is 
moderately fast, remarkably weak and low in tension. The heart may 
show no signs whatever, or simply slight dilation, with a famt soft systolic 
apex or basic murmur. The condition resembles typhoid fever. 

Sometimes the fever assumes the remittent or intermittent form, 
running a very mild course. In other cases the type is irregular, not 
very high but the anemia is rapid, the heart symptoms not prominent. 
Then again we may have rigors, sudden and lofty jumps of the tempera- 
ture followed by corresponding drops, with sweating resembling malaria, 
but without its typic periodicity. In other cases the fever type changes 
from week to week, but the pulse is always feeble and depression con- 
tinuous. Sometimes the local disease is shown by emboli in the skin 
or elsewhere. Small emboli in the skin cause petechias. Still other 
cases resemble acute hemorrhagic nephritis, with more fever. A special 
group of cases present less marked general sepsis, but a peculiarly soft 
pulse, too rapid for the fever, with dyspnea, cyanosis and enlargement 
of the liver and spleen. The heart may show increasing weakness, slight 
enlargement and possibly a soft murmur. 

The course of ulcerative endocarditis varies. Death may occur in 
a few days, or life be prolonged for months, sometimes with intervals 
of improvement. Death occurs from weakness of the heart or injury 
due to ulceration, from edema of the lungs, infarctions or exhaustion. 

Inspection and palpation may aid recognition of an old lesion, or 
the study of the pulse. Percussion reveals the dilatation or hypertrophy 
present, and the part of the heart so affected. Auscultation may detect 
changes in the character and relative intensity of the heart-sounds. Any 
aberration from the normal sounds will be found to increase if careful 
daily examinations are made. Presystolic murmurs are rare in acute 
endocarditis unless a mitral leak has previously existed. Systolic mur- 
murs at any of the valves may be accidental. The general symptoms 
may be due to the rheumatism. If the inflammation does not affect 
the valves, the diagnosis can only be made when embolism occurs. Peri- 
carditis is a much more painful disease; the friction murmur does not 



372 ACUTE ENDOCARDITIS 

usually coincide with a heart-sound, and the occurrence of effusion is 
significant. Pernicious anemia may closely simulate acute endocarditis 
without embolism. An examination of the blood may decide the diag- 
nosis. It is sometimes impossible to distinguish ulcerative endocarditis 
among the symptoms of general sepsis. In other cases the valvular 
indications are marked. The presence of a causal disease, however, 
generally gives a reliable -indication, especially if infarctions occur. Some- 
times the only symptoms pointing to the heart-disease are weakness of 
the pulse and muffling of the heart-sounds. In infectious maladies ab- 
sence of the usual leucocytosis points to malignant endocarditis. 

When we have satisfied ourselves as to the existence of acute endo- 
carditis, we should then ascertain the cause, determine the character- 
istics of the fever, examine the blood and the urine, ascertain whether 
hemorrhages into the skin or from the mucosa have occurred, search 
for embolisms, note whether the spleen is enlarged, and thus distinguish 
between the simple and ulcerative forms, that an intelligent prognosis 
may be made. 

Typhoid fever is confused with ulcerative endocarditis more frequently 
than any other disease. In typhoid fever we have a typical temperature 
curve, a pulse slow in proportion to the fever, early enlargement of the 
spleen, typical rose spots and stools, bronchitis, early epistaxis and late 
intestinal hemorrhage, and finally the Widal test, which is a certain means 
of distinguishing. 

Prognosis: — Benign cases may completely recover, but more fre- 
quently leave chronic disease. Mitral disease is less dangerous than aortic. 
Rapid dilatation of the heart indicates myocarditis, which is grave. An 
acute attack superadded to chronic disease of the valves is a serious 
occurrence, since it is usually malignant; and at any rate it hastens the 
progress of the cardiac malady. Embolisms of the brain cause paralysis; 
septic emboli are the more dangerous. The occurrence of hematuria 
is a bad indication. 

Treatment: — The first duty is prophylaxis. The treatment of the 
original infection should be prompt and effectual, especially as regards 
the care of the sick-room. Children susceptible to rheumatism should 
be carefully protected against it, and frequent examinations made of 
the heart. The slightest inflammation of the tonsils should be promptly 
and vigorously subdued. Babcock lays great stress on securing as much 
rest to the heart as possible during rheumatism and other infectious dis- 
eases, relieving the valves of strain as much as possible. This is especially 
important in the less acute attacks when the patient is usually unwilling 
to keep quiet. Confinement to bed is especially necessary when endo- 



ACUTE ENDOCARDITIS 373 

carditis appears, as inflammation is increased by exercise. Digitalis does 
harm by increasing systolic strain. Aconitine and veratrine, in full doses, 
would be likewise harmful but in small doses they are beneficial by in- 
creasing the inhibitory control over the heart, veratrine being also a direct 
tonic to its muscular tissue. Very small doses, gr. 1-134, of veratrine may 
be given with advantage every two to four hours. Cold over the heart has 
been strongly urged, as increasing the force of the heart's contraction as 
well as subduing the local inflammation. Babcock prefers hot applica- 
tions, claiming they are more stimulating. Counter-irritation relieves pain. 

We have as yet no data concerning the treatment of endocarditis of 
either form with modern antiseptic remedies; we are, therefore, limited 
to the application of those general rules which have been established by 
the study and application of the active principles. We therefore initiate 
treatment by completely clearing the alimentary canal and thus reliev- 
ing the patient from the depressing effects of fecal toxemia. Give calomel 
gr. 1-6 every hour for six doses, followed by an ample saline cathartic, 
and then enough of the sulphocarbolates to render the alimentary canal 
approximately aseptic. We may meanwhile seek to cope with micro- 
organisms in the blood or the tissues, by saturating the body as quickly 
as possible with calx sulphurata. 

Beyond this the treatment is strictly symptomatic. The above reme- 
dies are indicated in all infectious diseases, and it may well be that in some 
cases their action may suffice to enable the patient to cope with the malady 
himself. We cannot mistake, however, in affording him the powerful 
aid of the leucocytosis developed by nuclein. Of this the standard solu- 
tion should be gived to the full limit of its action in stimulating leucocy- 
tosis. Our experiments have shown that for this purpose the average 
adult daily dose is sixty minims. This should be given in divided doses, 
hypodermically or dropped upon the tongue, to be absorbed from the 
mouth and not subjected to the action of the gastric juice. 

As to the symptomatic treatment, we will simply mention the follow- 
ing: For pain and restlessness, codeine, cannabin, iodoform and cam- 
phor monobromide; for fever, aconitine, veratrine and gelseminine; for 
insomnia, camphor monobromide; for general and heart weakness, strych- 
nine or brucine; for threatened collapse, atropine; for restlessness, zinc 
valerianate; weakness of the right heart demands the addition of con- 
vallamarin; cactus is a good, mild heart-tonic. Digitalin is usually harm- 
ful, and the venous engorgement which specially indicates this agent is 
not a feature of this disease. 

The diet should consist of small quantities of the richest nutrition 
to be found, predigested, and alternated with small cups of strong coffee, 



374 CHRONIC ENDOCARDITIS 

the latter an admirable heart-tonic itself. Failure of the urine should 
be met by the injection of normal salt solution into the colon. 

In the ulcerative form, it is especially necessary to apply the general 
treatment above described. The usual treatment offers no encourage- 
ment whatever. We are therefore fully justified in laying it aside for 
anything which appears to deserve a trial, and the evidence in favor of 
the active principle method in the treatment of other infective processes 
warrants the hope that its application here may prove at least somewhat 
more successful than the despairing suggestions made in the text-books. 
Sansom is quoted by Babcock as reporting one case in which a patient 
improved so much under sodium sulphocarbolate that she left the hospital. 
She returned and died of a fresh attack in ten months. It is not said what 
was her treatment during the interval of the second attack. Babcock 
attributes the benefit from such remedies to their local antiseptic action 
in the intestines, since as he says, "Fermentative processes and diarrhea, 
as shown by fetor of the discharges, are very common within the digestive 
tube of patients suffering from sepsis. Such a condition may not only 
intensify the pyrexia and other symptoms of infection, by itself setting 
up an infection of intestinal origin, but it prevents the proper digestion 
and assimilation of nourishment. If now this putrefactive fermentation 
can be prevented by intestinal antisepsis, the patient's nutrition will 
improve and his tissue resistance be augmented. It is possible, per- 
haps, by having this additional enemy thus removed, the system may 
be able to cope successfully with the primary invader." 

The early and efficient use of antitoxin in diphtheria is the most 
effective means of preventing the development of malignant endocarditis; 
and should also be employed although with less hope of success, as a 
means of treating this malady. The other serums are much less satis- 
factory. We must, however, call attention to the importance of empty- 
ing and completely disinfecting the primary focus whence the infection 
is derived, whenever it be possible; even though this may be comparatively 
small, the most malignant infective process will be found there. 

CHRONIC ENDOCARDITIS 

The fibrinous deposits of acute endocarditis are largely absorbed, 
but the surface remains roughened. The tissue of the valve is infiltrated 
with new connective, and as this becomes organized it contracts, caus- 
ing deformity of the valves and consequent imperfection in their function. 

In arteriosclerosis the endocardium, especially of the aortic valve, 
is involved. The mitral valve may also be affected. The sclerosis is 
here primary. 



CHRONIC ENDOCARDITIS 375 

The deformity of the valve may result in imperfection allowing part 
of the blood it should intercept to flow backward, or adhesion of the 
edges of the valve leaflets may narrow its orifice so as to obstruct the 
onward flow of the blood through it. The first constitutes a leak, allow- 
ing regurgitation; the technical designation of the lesion being insufficiency. 
The second is known as "stenosis". The two often coexist, the valve being 
partly obstructed and also leaking. Obstruction may be in part due to 
thickening and stiffening of the valves, and to the remains of vegeta- 
tions which have become organized. Insufficiency causes an abnormal 
quantity of blood to fill the cardiac chamber behind the leaky valve, 
inducing dilatation and hypertrophy of the muscular fibers, by which 
the blood is forced through the orifice and the circulation maintained. 
Stenosis leads to hypertrophy without preliminary dilatation, the cavity 
contracting as the supply of blood is not increased. The chamber in 
front of the defective valve, receiving a smaller supply, becomes atrophied 
and contracted. The blood supplies to the arteries being reduced in 
quantity they contract, the veins are overfilled and the capillaries dilated 
with venous blood. 

Changes in the myocardium and pericardium usually accompany 
or follow. 

Etiology: — Sclerosis may be due to age, gout, nephritis, arteriosclerosis, 
or local strain. The tendency to it is probably hereditary. Old age — 
physiologic rather than chronologic — is denoted by sclerosis. Sedentary 
life with a large consumption of animal food and alcohol determines the 
whole group of maladies causative of this process, whether the direct 
exciting cause be gout, cirrhotic nephritis or arteriosclerosis. The modus 
operandi is supposed to be the induction of strain, mechanical, long- 
continued, by abnormal vascular tension. Constipation, indigestion, 
autotoxemia, afford elements of an irritant nature to the blood that 
should not be ignored. Very laborious occupations contribute to the 
strain. Tobacco and syphilis are credited with causal influences, which 
seem less obvious, though the latter may affect the heart muscle and the 
endocardium directly. The most important cause, at least in the young, 
is rheumatism. The original attack may be overlooked and the disease 
progress unsuspected for years, until the failure of compensation first 
directs attention to its existence. Mitral stenosis is the form most fre- 
quently arising from this cause. 

Symptoms: — When exact compensation exists there are no subjective 
symptoms. Mitral affections present marked venous congestion, while 
aortic imperfections display the evidences of insufficient arterial supply, 
both manifesting these two elements in varying proportion. Some of 



376 MITRAL LEAK 

the later manifestations are due to the interference with digestion, the 
altered circulatory conditions, the pulmonary engorgement, complications 
and intercurrent maladies to which the heart lesion may open the door, 
the occupation, the assumption of marital relations, pregnancy and lacta- 
tion, embolism and thrombosis. 

The cardiac cachexia is at least partly due to chemical changes in the 
blood. It displays debility, anorexia, indigestion, and often indisposition 
as well as inability for physical and mental labor. Palpitation and attacks 
of pain in or about the heart are common, as well as irregularity of cardiac 
rhythm. These occurring in individuals in whose hearts no lesion can 
be detected are possibly of toxemic origin, but the fact that the mani- 
festations occur in the heart stamps that organ as a point of low resisting 
power, hence liable to disease. 

MITRAL LEAK 

Regurgitation being a symptom consequent upon the lesion, that term 
does not seem appropriate as a designation for the malady. While we 
may term it incompetence or insufficiency, the word "leak" is good Anglo- 
Saxon, accurately descriptive of the lesion and conveying instant appre- 
hension of the true difficulty to the mind of any student. 

As the left ventricle contracts part of its blood is squeezed back into 
the auricle. The trouble is due generally to deformity of the valve leaf- 
lets. When the cavity is enlarged the valves usually elongate so as to close 
the orifice, so that imperfection from this cause is infrequent. 

Pathology: — The leaflets become thick or rigid, curl up, or the chordae 
shorten till the valve can not close. Remains of vegetations may be found 
on the margins, sometimes calcified. These cause stenosis also. The 
calcareous deposits may be quite large. The blood flowing back into 
the auricle meets the oncoming blood delivered by the pulmonary veins, 
overdistending the left auricle. This stimulates its walls to increased 
action, which induces hypertrophy. If this be exactly sufficient for the 
need, the circulation is maintained and this condition of equilibrium 
may endure to the full expectancy of life. But if the leakage be great, 
the auricle does not completely empty itself and an accumulation of blood 
takes place in it. This obstructs the outflow of blood from the pulmonary 
veins, which, they becoming congested, hinders the delivery of blood 
from the pulmonary capillaries, which in turn become engorged. This 
offers an obstruction to the outflow of blood through the pulmonary ar- 
tery, and into it from the right ventricle, which in turn becomes hyper- 
trophied to meet the increased resistance. This is the point where com- 



MITRAL LEAK 377 

pensation is usually established, and as a rule this is sufficient to force 
the blood through the entire vascular apparatus into the aorta, compen- 
sating completely for the defect and maintaining the circulation. But this 
is done at the cost of increasing the pulmonary engorgement, changing 
it from a passive congestion to an active hyperemia; and whatever symp- 
toms are relieved, the patient suffers continuously from the pulmonary 
engorgement. Hyperplasia of the pulmonary connective results in time, 
while catarrhs, hyperemias and pulmonary edemas are frequent transitory 
features. When the limit of compensation has been reached the right 
ventricle yields to the strain and dilates. This condition rapidly in- 
creases as the blood-pressure within the ventricle becomes greater; the 
tricuspid valve is unable to fill the gap and blood regurgitates into the 
right auricle; this becoming dilated, offers an obstacle to the influx of 
blood from the venae cavae, and the entire venous system becomes 
passively congested. The engorgement is most markedly manifested 
in the liver, which enlarges, and the entire portal system to which the 
obstruction is transmitted in turn becomes engorged with blood, the spleen 
enlarging, the stomach becoming congested as well as the intestines, 
interfering with the digestion and absorption of food by the direct back- 
pressure, and giving rise to catarrhal conditions, diarrhea, hemorrhoids, 
ascites, etc. The entire venous system is congested, and dropsy with 
cyanosis supervenes. All the viscera in time show morbid alterations 
due to this disturbance of the circulatory conditions. The dropsy begins 
in the lower extremities and extends upwards. 

Some hypertrophy occurs in the left ventricle, which is attributed to 
the increased quantity of blood discharged into it by the auricle, owing 
to the occurrence of excessive hypertrophy of the right ventricle. The 
left ventricle also dilates in due time, the muscular tissue having become 
flabby, the fibers smaller, and containing brown pigment granules. The 
whole heart is therefore enlarged in time, especially the right ventricle. 

Etiology: — The causes are those of chronic endocarditis. This is 
the most frequent of all defects of the heart valves, especially in the young, 
in whom rheumatism, chorea and the infectious fevers are most frequent. 

Symptoms: — If compensation is exact, there are no subjective symp- 
toms. Many unsuspected cases are detected, when for any reason the 
patient undergoes an expert physical examination. Some persons apply 
to the physician on account of the digestive affections, constipation, pains 
about the heart, or palpitation. Women may display nervousness or 
anemia, short breath or palpitation after exertion. Rarely the pain about 
the heart is severe, even amounting to angina. Dyspnea is a common 
symptom when compensation has become imperfect, and is manifested 



378 MITRAL LEAK 

after continually slighter exertion. The pulmonary engorgement renders 
these patients very liable to catarrhal attacks, which generally settle into 
the chronic form, worse in cold weather. Patients often complain of the 
sensation of a hair in the larynx. Hemoptysis is very common in the 
later stages when any unusual exertion, by increasing the pulmonary 
congestion, may bring on coughing. Edema of the lungs may occur. 
As long as the right ventricle sustains the circulation, this comprises the 
symptoms usually manifested. If the hypertrophy be excessive, cerebral 
hyperemia results, and apoplexy may occur, cerebral or pulmonary. 
When the right ventricle has given way and the blood is backed up into 
the general venous system, we have enlargement of the liver, with dull 
soreness, the appetite is lost, nausea is easily induced and gastric catarrh 
arises, with its innumerable phases. Intestinal catarrh also follows with 
tympanites, diarrhea, intestinal hemorrhages, hemorrhoids and a large 
variety of symptoms due to intestinal engorgement. Great thirst is com- 
mon. Sometimes the appetite is excessive; the food not being digested, 
absorbed and assimilated, tissue hunger is not satisfied. The pehic or- 
gans becoming congested menstrual troubles arise, the flow being some- 
times but not always excessive. Renal disorder is manifested by pale, 
scanty urine, with albumin and casts after dropsy has commenced. The 
liver is tender, and the intestinal catarrh extending into the gall-passages 
causes a degree of jaundice; the cheeks show a dark flush, the lips appear 
as if stained by mulberries; the cutaneous veins are prominent; and 
after the patient has been on his feet during the day he is apt to complain 
of his shoes being tight, as the ankles swell towards evening. By morn- 
ing this has disappeared; but as the dropsy increases edema may be 
detected along the back or other dependent portions. Shortness of breath 
increases and occurs after slighter exertion; uncomfortable sensations 
are felt in the region of the heart, differing from the sense of oppression 
in the chest experienced while the disease has not progressed beyond 
compensatory hypertrophy of the right ventricle. A notable symptom 
is the effort required to talk while walking. Perspiration occurs readily 
and fatigue is quickly induced. Sometimes the patient becomes drowsy 
after meals or when sitting quietly. These patients find it especially 
difficult to endure a close, hot room. The sleep is disturbed by unpleasant 
dreams and nightmares; or the patient drowsy by day is wakeful and 
restless on lying down. Headaches may be due to active hyperemia while 
compensation is still perfect, and to passive congestion later. As com- 
pensation subsides dropsy creeps up, reaching the abdomen and invading 
the serous cavities, the peritoneum, pleura and pericardium, interfering 
markedly with respiration and greatly increasing the patient's discomfort. 



MITRAL LEAK 379 

The legs become cool, smooth, white and shining, bed-sores may form, 
or the skin may break. The slightest rupture or wound is apt to be fol- 
lowed by erysipelas. Feeding becomes more and more difficult; the 
cerebral congestion gives rise to continuous dull headaches, with irritability, 
and sometimes a typhoid condition; the patient grows less and less able 
to obtain comfort with the head low and gets in the habit of spending 
the day and night in a chair; exercise growing more difficult on account of 
the short breath, the patient is able to walk only with a nurse on each 
side sustaining her, and slipping the feet along the floor inch by inch, 
without raising them. Any change of posture becomes of increasing diffi- 
culty. The patient when in this condition may die at any moment, the 
heart stopping at any exertion or emotion. The abrupt entrance of a 
friend into the room may cause the feeble fluttering of the heart to cease. 
Finally such a patient will be found dead in the chair, the candle, burnt 
to the end, having flickered out. 

If nephritis enters into the case, as an original cause or as secondary 
to the loss of circulatory equilibrium, we may have uremic symptoms 
intervening. Sudden paroxysms of dyspnea occur, generally worse at 
night; headache and nausea are more common, and intercurrent serous 
inflammations occur. The dropsy is more difficult to treat. Edema 
of the lungs, brain or elsewhere may appear swiftly. Excepting when 
the kidneys are diseased, cardiac asthma is not common. If ascites oc- 
curs independently of general dropsy, it is most generally due to adherent 
pericardium. Embolism may occur during or after an intercurrent at- 
tack of acute endocarditis; the symptoms varying with the organ to which 
the embolus is carried; in the kidney it causes hematuria; in the brain 
it usually enters the left middle cerebral artery, causing aphasia or paral- 
ysis of the right side; in the hepatic artery it causes acute jaundice and 
atrophy; in the spleen a sudden sharp pain with swelling and tenderness; 
in an extremity it causes pain, pulsation ceases in the artery below it 
and the limb becomes weak, numb and cold; gangrene may follow, es- 
pecially in the legs. Emboli deposited in the lung cause infarctions, 
with pain and hemorrhage. If the pulmonary artery is blocked, death 
occurs quickly. 

Physkdl Signs: — Inspection recognizes the evidence of capillary con- 
gestion in the face and lips, cyanosis later. In children the fingers club, 
the shoulders stoop, there is bulging in the region of the heart, and growth 
is stunted. Nothing of the kind is manifested in older patients. As the 
heart is hypertrophied its weight drags it down, and the varying hyper- 
trophies displace the apex to the right or left. Epigastric pulsation in- 
dicates hypertrophy of the right ventricle. 



380 MITRAL LEAK 

Palpation shows a pulse of low tension, rapid but regular; until com- 
pensation weakens, when the pulse becomes deranged in rhythm and 
feeble. This is more readily recognized if the arm is raised. The degree 
of enlargement of the heart may also be estimated by palpation. A sys- 
tolic thrill may be. felt at the apex. The enlarged right ventricle may 
be felt pulsating at the epigastric notch. 

Percussion shows the enlargement of the heart, under and to the right 
of the sternum, in right-sided hypertrophy; to the left, beyond the nipple, 
in left-sided enlargement. Auscultation detects murmurs replacing the 
normal sounds of the heart. In mitral insufficiency the murmur is heard 
most distinctly at the apex, with the first sound of the heart, when the 
ventricle is contracting and some of the blood regurgitating through the 
imperfectly closed mitral valve. The existence of such a murmur is not 
alone sufficient evidence of mitral imperfection, as the murmur may be 
accidental, or due to abnormal vibration of the valves. Any lesion of the 
valve which will cause a murmur will also give rise to such conditions as 
we have described, at any rate to enlargement of the left auricle and some 
congestion of the lungs. As these valve lesions are frequently multiple 
there may be a presystolic murmur at the apex, indicating a degree of 
obstruction also; or other murmurs heard at the base may show involve- 
ment of the aortic valves; while in due course of time the tricuspid and 
pulmonary valves also contribute their signs. Sometimes the mitral 
sound is more distinct over the tricuspid area, which shows the importance 
of considering the concomitant symptoms as well as the murmur. The 
murmur may be heard more distinctly while the patient is. still panting 
after exercise. Sometimes it is best heard when the patient is lying down. 
The organic murmur is generally transmitted widely and toward the 
axilla, while accidental murmurs are much more contracted. The pul- 
monary second sound is intensified. 

Diagnosis: — When the disease has progressed the diagnosis is easy. 
Late in the course of the malady it may be difficult unless the history is 
clear. The physical signs already given suffice, when in harmony with 
the history and the original cause has been ascertained. Being familiar 
with the course of the malady, the extension of the disease process may 
be estimated, and the prognosis deduced. This depends on the original 
cause, the secondary effects, the condition and persistence of compensa- 
tion, and the presence of complications. Sclerosis is progressive. A 
large leak is more dangerous than a small one. Excessive over-compensa- 
tion brings its own dangers and is less enduring than a compensation just 
sufficient for the defect. The age, occupation ^and tractability of the 
patient are to be considered. 



MITRAL STENOSIS 381 

Sudden death is not a feature of mitral disease, unless the heart muscle 
is degenerated. Death from embolism is rare. Usually the case is pro- 
longed with constantly increasing distress, until death is welcomed by 
the patient and the friends. 

MITRAL STENOSIS 

The lumen of the valve is lessened by adhesion of the margins of the 
leaflets, which may extend almost to the apex, leaving only a buttonhole 
orifice; or the opening may be occluded by inflammatory products, by 
which the valves are distorted. Stenosis without insufficiency is almost 
unknown. The narrowing of the valve necessitates a more rapid flow 
of the blood through it and this induces hypertrophy of the left auricle. 
Dilatation of the auricle only occurs when its hypertrophy has become 
insufficient to force all the blood through the continuously narrowing 
orifice; hence, hypertrophy of the auricle precedes dilatation in mitral 
stenosis, the converse being the case in insufficiency. Meanwhile the 
ventricle, illy supplied with blood for its work and its nutrition, becomes 
contracted and atrophied. The same evidences of obstructive circulation 
follow as in mitral leakage, the blood being backed up in the pulmonary 
veins, pulmonary capillaries and pulmonary artery to the right ventricle, 
upon whose hypertrophying walls the patient must depend to sustain the 
circulation. This is, however, more difficult than in mitral insufficiency. 
The myocardium becomes atrophied, and the same congestive effects 
are manifested throughout the body as are described in the preceding 
chapter. 

Etiology: — We need not repeat here what has been said in the preced- 
ing chapter, since the same causes apply; but stenosis is always due to 
structural defects, acute inflammation inducing incompetence. If in 
such cases stenosis develops it is at some subsequent period. Rheumatism 
is therefore the most common cause and the malady is progressive. It 
more frequently depends upon the slighter attacks of rheumatism, which 
are less likely to receive due attention and treatment. Tuberculosis has 
also been assigned as a cause of this malady. Syphilis and gout are 
causes of the sclerotic form occurring in advanced years. This defect is 
much more frequent in females; so far as the rheumatic endocarditic form 
is concerned, the sclerotic form being equally common in both sexes. 

Symptoms: — The course and symptoms are practically identical with 
those of mitral leakage. Stenosis is less likely to remain at a standstill 
for many years. Occurring in young children, development, mental and 
bodily, is apt to be imperfect. In adults the circulation is weak, the 



382 MITRAL STENOSIS 

extremities cold, the patient anemic and very sensitive to cold. Digestive 
and menstrual troubles are common in women, with constipation; the 
urine scanty and concentrated. Bronchial catarrhs and acute edema of 
the lungs are more common than in insufficiency. Dyspnea on exertion 
also occurs early; in fact, when we realize that the pressure exerted in the 
pulmonary circulation is even greater than it is in mitral leakage, the 
predominance of pulmonary symptoms is readily appreciated. The sense 
of fullness and oppression in the chest is usually marked; patients complain 
of vertigo on suddenly arising after lying down. Sleep is much disturbed. 
Pulmonary hemorrhages and hemoptysis are common; in time the right 
ventricle gives way, the tricuspid valve opens and venous stasis extends 
through the entire venous tract. 

The ending is similar to that in mitral insufficiency. The physical 
signs in general resemble those described in the last chapter: Palpation 
may detect a thrill at the apex, preceding the ventricular systole; resembling 
the purring of a cat, it is known as jremissement cataire. The systole 
following is short and sharp; epigastric pulsation is usually pronounced. 
The pulse is weak and slower than in insufficiency. The degree of irregu- 
larity probably depends upon the condition of the heart muscle. Occa- 
sionally there is a difference in the two radial pulses, the left being smaller. 
This is observed when compensation fails. Percussion shows evidence 
of enlargement of the right heart. Auscultation reveals the characteristic 
murmur. Babcock describes it as "a long-drawn bruit, following the 
second sound and ending in the cleai sharp first sound. " It is most distinct 
at the apex and is synchronous with the auricular systole, ■ The murmur 
cannot usually be heard beyond a limited area, where the thrill is most 
plainly felt. Obstructive bruits are always rougher than those of regur- 
gitation. This may be hear/1 most distinctly when the patient is lying 
down, but in some cases the reverse is the case. This murmur is not uniform 
as heard at different times and conditions. Sometimes the bruit is very 
short; at others very long. The second cardiac sound and sometimes 
both sounds may be inaudible. The short, thumping first sound may 
be so marked as to permit a diagnosis to be made from it alone. The 
second sound is sometimes apparently double, when the heart is compar- 
atively strong. 

The diagnosis is usually easy. Stenosis is more common in females. 
The thrill followed by a short, sharp, systolic beat, the dullness indicating 
right ventricle enlargement alone, the rough low-pitched presystolic 
murmur, the double second sound, the marked pulmonary symptoms, 
the small weak pulse and regular rhythm, sufficiently distinguish this 
condition. 



AORTIC LEAK 383 

When the nature of the lesion has been diagnosed, we have to determine 
the stage of the malady's progress, the patient's resisting power and the 
other elements, from which we can form an estimate of the probable results. 
Repeated examinations at intervals will show the rate of progress to be 
expected. The prognosis is less favorable than in incompetence, the 
pulmonary congestion being greater and the malady more frequently 
progressive. The average duration of these cases has been estimated at ten 
years. Death results from progressive heart weakness, pulmonary compli- 
cations and infarctions. In the last stages slight excitement or exertion may 
cause death. Acute pulmonary inflammations are common and fatal. 

AORTIC LEAK 

Imperfection of the aortic valve permits a portion of the blood entering 
this vessel to flow back into the left ventricle when the artery contracts. 

Andtomy: — The lesions found closely resemble those already described 
as appearing in the mitral valve. Sclerosis is more common in the aortic 
valve. The leaflets may be contracted or twisted, or their complete closure 
prevented by growths at the margin. We do not, however, find contracted 
chords. Ulceration may perforate a valve leaflet, or it may be ruptured 
during violent exertion. This is probably impossible unless the valve 
was previously weakened by disease. Stenosis coexists frequently but not 
always. As a first result of the imperfection the left ventricle becomes 
dilated by the double flow of blood into it. Hypertrophy follows and 
develops early, often greatly exceeding the need. The wall of the ventricle 
may become enormously thick, projecting into the cavity of the right 
ventricle. When the mitral valve becomes imperfect the symptoms 
already described as due to that lesion will be developed. The double 
hypertrophy thus occasioned increases the sizerof the heart enormously; this 
is known as cor bovinum, and one has been reported weighing six pounds. 
The force exerted by such a ventricle subjects the aortic walls to great 
strain, and sclerotic changes follow. WTien the valvular disease occurs in 
elderly persons with arteriosclerosis the hypertrophy is slight; as a result of 
the disease of the coronary arteries lessening their lumen and interfering 
with the nutrition of the heart, degeneration following. 

Etiology: — Rheumatic cases occur in young males. The sclerotic 
form is also more common in males. Incompetence sometimes occurs 
from enlargement of the ventricle, stretching the basal ring to which the 
valves are attached. This may be occasioned by degeneration of the 
heart-muscle, aortic disease or mediastinal tumors compressing the aorta. 
Aortic aneurism is a frequent cause. 



384 AORTIC LEAK 

Symptoms:—- When compensation is established the disease may remain 
at a standstill for years, considerable physical exertion being indulged 
in with impunity. The patient may be unconscious of the existence of 
a heart malady. Unless hypertrophy be pronounced, the arterial system 
is not well filled and anemia with innutrition results. This is exceptional. 
Some persons are affected with palpitation, or dizziness, especially after 
exertion. The hypertrophy, however, is usually great, and while it endures 
the aortic circulation is more than maintained, the brain is flooded with 
blood, and sometimes bleeding at the nose gives temporary relief. As 
the lesion increases we may have on the contrary an alternation of cerebral 
anemia and hyperemia, causing distressing vertigo and attacks of syncope. 
These patients lie with the head low; those with mitral disease with the 
head high. Digestive disorders are not so common as in mitral disease; 
but owing to the weak circulation and the small supply of blood patients 
suffer with a chronic dyspepsia, and any excess in diet brings quick retri- 
bution. Nor are the pulmonary symptoms present unless the mitral 
valve is also involved. There is apt to be pain about the heart, more marked 
than with mitral disease. The sclerotic type is especially grave as degener- 
ation of the heart-muscle precedes the valvular lesion, and the nutrition 
of the heart suffers still further from an insufficient supply of blood through 
the coronary arteries. 

Failing compensation is indicated by the weak, irregular and inter- 
mitting pulse. Pulsus intercurrens occurs. This increases as the difficulty 
grows greater; dyspnea, vertigo and syncope increase; sudden death may 
occur at any time; or symptoms indicating collapse, with dyspnea, cyanosis, 
an empty pulse and sense of impending death. Pulmonary stasis now 
occasions hyperemia and edema of the lungs, with hemoptysis. Angina 
pectoris is much more frequently seen with aortic than with mitral disease. 
These aortic cases may be divided into two groups; the younger, in whom 
endocarditis follows rheumatism or other infectious diseases; and the 
elderly, in whom it is part of a general vascular sclerosis. Hypertrophy 
only occurs in marked degree with the first class, and fails early. When 
compensation fails, however, in the second class, the end comes rapidly. 

Inspection shows throbbing of the superficial arteries, with the powerful 
pulsations of the great left ventricle, which may shake the chest. The 
apex beat is displaced outward and downward; in elderly patients it may, 
however, be scarcely perceptible. Visible pulsation in peripheral arteries 
indicates excessive hypertrophy. This may also be seen in the retinal 
artery. Palpation distinguishes the powerful heart-beat. A presystolic 
thrill may be felt over the apex, a systolic and sometimes a diastolic thrill 
over the aortic valve. The peculiar pulse has been called the Corrigan, 



AORTIC LEAKS 385 

collapsing, water-hammer, locomotive, and pulsus alter et celer. It is a 
powerful stroke, not sustained but subsiding instantly. The reason for 
this is evident from the mechanical conditions of the circulation. Some- 
times the stroke is doubled. The arteries in the patient's fingers may 
sometimes be felt to pulsate while we hold his hand. Quincke's sign 
is the capillary pulse, best seen in the palm and beneath the nails, when 
the hand is warm or after rubbing the skin until it is red. At the margin 
of the red patch the heart's pulsations may be noted. Sometimes pulsation 
is visible in the superficial veins. 

If the leakage is serious, a thrill may be imparted to the cervical and 
brachial arteries. 

By percussion we judge of the heart's size. The enlargement of the 
left ventricle increases the dull area to the left and downwards, the apex 
becoming broader as dilatation supervenes. Aortic insufficiency causes 
a murmur replacing the second heart-sound, usually most distinct in the 
second intercostal space at the right margin of the sternum, or a little 
lower. Sometimes this murmur is heard most distinctly to the left of the 
sternum, in the space where the pulmonary valve is usually heard. The 
distinction is made by the history and symptoms, pointing unmistakably 
to disease of the aortic valve. Aortic sounds are most distinct after exertion 
and when the patient is standing, exceptionally when lying down. ' There 
is no special relation between the loudness of the murmur and the gravity 
of the disease. At the apex the first sound may be muffled, the second 
sound feeble. The second aortic sound may be faint or wanting. Double 
murmurs at this valve are frequent. Faint systolic murmurs may be heard 
over the carotid and subclavian arteries. Over the femorals a sharp 
snap may be heard synchronous with the first heart-sound. This disap- 
pears when the vessel is pressed upon by the stethoscope, being replaced 
by a murmur. A diastolic murmur may also be elicited, the double 
murmur known as Duroziez 's sign. 

Diagnosis: — Difficulty is not apt to be met except in case of the aged. 
The first importance must be given to symptoms denoting irregularity 
of the circulation rather than to the murmur. The prognosis depends 
upon compensation. When the disease has been caused by endocarditis, 
compensation may endure for many years; when this fails the prognosis 
is graver than in mitral disease. In cases due to degeneration compen- 
sation is briefer, and when once lost the progress is more rapid. The 
rare occurrence of stenosis is favorable. The sudden deaths occurring 
in heart disease are especially common in aortic maladies, the left ventricle 
stopping in diastole. There may have been vertigo, but usually not enough 
to warn the patient. Death follows some sudden effort. Such cases 



386 AORTIC STENOSIS 

are, however, exceptional; more frequently death is preceded by degener- 
ation of the heart-muscle. Otherwise, the last stages resemble those of 
mitral disease. 

AORTIC STENOSIS 

In most cases this disease accompanies the preceding form. The 
valve leaflets may adhere at their edges or vegetations and other growths 
may obstruct the lumen of the valve. The former may be congenital or 
due to acute inflammation. Sclerosis causes insufficiency as well as 
stenosis. The same may be said of vegetations. Sometimes the aortic 
ring, or the trunk of that vessel, becomes contracted; this is generally 
congenital. Whatever be the cause and form of the malady, it constitutes 
an obstacle to the egress of blood and this induces hypertrophy of the left 
ventricle. Dilatation follows hypertrophy, occurring as compensation 
fails. When the supply of blood to the coronary arteries is interfered 
with, the nutrition of the heart suffers and degeneration of its muscular 
fiber follows. 

Etiology:— A few cases are congenital. Usually the disease is due to 
endocarditis in the young, or'sclerosis in the aged. 

Symptoms:— There may be none. When the obstruction is, extreme 
we see the effects of a diminution of the blood-supply in general, innutrition 
and feebleness of function, as well as stasis behind the obstruction. Slight 
forms may exist for years unsuspected; even to old age following a life of 
average activity. At other times the patient is simply below the average 
of physical capacity; others are liable to fainting fits, vertigo or even 
convulsions. When failure of compensation begins the left ventricle 
dilates, the pulse grows feeble and irregular, mitral insufficiency follows 
and the circulation is backed up through the lungs, as in primary mitral 
disease. The right ventricle enlarges in turn, and the symptoms of venous 
engorgement already described are manifested. Mitral leakage relieves 
the engorgement of the left ventricle and checks its dilatation. 

In the early stages the patient is pale; cyanosis follows mitral implica- 
tions. The left ventricle hypertrophy displaces the apex beat downwards 
and outwards; the heaving pulse of the enlarged ventricle is less marked 
than in aortic leakage. In very fat persons palpation may not detect it. 
When the ventricle dilates this heave is weakened. A thrill may often 
be felt in the aortic region with the ventricular systole; the pulse is small 
and weak, slower than normal, until degeneration occurs in the heart- 
muscle. The sphygmographic tracing shows an oblique ascent, rounded 
summit, gradual descent and indistinct secondary waves. The cardiac 
dullness is increased downward and outward. The usual signs of right 



TRICUSPID LEAK 387 

ventricle enlargement follow late. The first sound at the apex is dull 
and muffled; the distinctive murmur is heard in the aortic area, in the 
second intercostal space to the right of the sternum, with the first heart 
sound. It is usually quite distinct and may be heard along the course of 
the great arteries. 

Diagnosis: — The characteristic murmur, with hypertrophy of the left 
ventricle and weakness of the aortic second sound, usually suffice for a 
rheumatic person under forty years of age. Sclerosis occurs after mid-life; 
the arteries generally are stiff and tortuous, the aortic second sound is 
accentuated and ringing, the whole heart usually enlarged. Syphilis, 
rather than rheumatism, is then the history. Aortic aneurisms occur in 
patients over forty with a history of syphilis or strain, rigid arteries, and 
present symptoms of pressure such as pain, cough and dyspnea, unequal 
pulses in the two arms, the heart displaced rather than enlarged, with 
the pulsation and, possibly, the bruit. The x-ray confirms the diagnosis. 
This is often difficult; accidental murmurs may occur in the young, espe- 
cially in women, not rheumatic but anemic, without hypertrophy or other 
evidences of circulatory derangement. 

The prognosis depends upon the cause. Sclerosis does not stop with 
the single valve lesion; the hypertrophy following it is brief, the downward 
progress rapid; sudden death may occur. Inflammatory cases in the 
young may cause little difficulty unless the narrowing becomes extreme and 
compensation fails. As with leakage, failing compensation is more 
serious than in the corresponding mitral disease. Sudden death rarely 
occurs. The course resembles that of mitral disease but is more rapid. 

TRICUSPID LEAK 

This is the most common disease of the right heart. Primarily oc- 
curring it is congenital; otherwise it follows mitral disease. The ana- 
tomic changes are analogous to those occurring at the mitral valve; leak- 
age and stenosis usually coexist. Relative insufficiency attends extreme 
dilatation of the right ventricle. The great veins become also distended; 
the heart muscles in time become degenerated. Some authors claim 
that this tricuspid disease prolongs life, by relieving the right ventricle 
of a distention that would otherwise prove fatal sooner than it does with 
the valve leaking. 

Etiology: — Endocarditis previous to birth occurs most frequently 
at this valve. Occurring after birth the causes are those of the precedent 
left heart diseases. Atonic dyspepsia is frequently found in connection 
with anemia and tricuspid regurgitation, the latter probably being the 



388 TRICUSPID STENOSIS 

causal factor. Gibson attributes to continued fever a pronounced causa- 
tive influence. Severe exertion such as climbing mountains throws a 
strain upon the right ventricle which may induce dilatation and relative 
tricuspid incompetence, the latter serving as a safety valve. Any other 
violent exertion may have the same effect. 

Symptoms: — A description of a case of tricuspid regurgitation by 
itself would be strictly scholastic, as such cases scarcely ever exist. Ob- 
viously the symptoms would be those of venous engorgement, the blood 
being backed into the venae cavae and their roots. Venous pulsation is 
present; the liver enlarges; cyanosis and dropsy occur in due time. Before 
this debility is manifested we have interference with digestion, diarrhea, 
hemorrhoids and enlargement of the spleen. The serous cavities are 
said to be apt to fill up with serum rather than general dropsy to occur. 
Cough and dyspnea would not be as marked in primary tricuspid disease 
as they are in the form following mitral disease. Babcock attributes 
the rapid failure in nutrition and development of dropsy, occurring when 
the tricuspid has become involved, to the obstruction presented to the 
escape of its contents from the thoracic duct, by venous tension. 

Inspection shows dilatation and pulsation of the jugulars, these vessels 
collapsing during their diastole; other superficial veins are also dilated. 
Palpation of the liver may also detect venous pulsation there. The 
arterial pulse is small and weak, sometimes irregular and intermittent. 
Dropsy is a late symptom. The coexistent disease usually renders per- 
cussion of little or no value. Otherwise it will show an increase of the 
cardiac dullness to the right. Auscultation shows a murmur with the 
first heart-sound, heard most distinctly over the ensiform cartilage, ex- 
tending upward and to the right. The heart sound is muffled or replaced; 
the second sound may be accentuated. 

Diagnosis: — The murmur alone must not be depended upon; but 
the symptoms caused by leaking at this valve are too significant to be 
misunderstood by anyone who comprehends the circulation. The prog- 
nosis depends upon the state of the primary disease. Relative incom- 
petence due to over-exertion usually subsides quickly under proper care. 
Death occurs from the prolonged exhaustion. 

TRICUSPID STENOSIS 

This is probably the rarest of valvular diseases. It may be congenital 
or acquired; the former may be caused by inflammation or may constitute 
a defect in development. In the latter case other defects of the circu- 
latory apparatus often coexist. Inflammation causes thickening, stiff- 



TRICUSPID STENOSIS 389 

ness or adhesion of the leaflets, and vegetations. Insufficiency usually 
coexists. The neighboring parts of the heart-muscles may be involved. 
The right ventricle becomes hypertrophied and in time dilated; but if 
the tricuspid obstruction is great and regurgitation slight, the ventricle 
contracts; the right auricle, however, becomes greatly dilated and some- 
what hypertrophied. 

Etiology: — Occurring posterior to birth, the cause is inflammation, 
generally rheumatic. Syphilis may also be the cause, or puerperal con- 
ditions. The disease is much more frequent in females, and between 
twenty and thirty years of age. 

Symptoms: — Most cases have first been diagnosed on the post mortem 
table. The preexisting mitral disease usually completely overshadows 
this. There is no dyspnea, because the blood furnished the lung is dimin- 
ished in quantity. The pulmonary tract in fact is comparatively empty, 
as well as the arterial system, while behind the tricuspid valve we find 
engorgement from the blood backing up successively to the right auricle, 
the venae cavae, the hepatic veins and the roots of the portal system and 
of the venae cavae. Capillary stasis results with cyanosis and dropsy 
beginning at the feet and extending upward. Portal stasis gives rise to 
gastric and intestinal catarrh, hemorrhage and diarrhea, anorexia, indi- 
gestion and innutrition, enlargement of the spleen, hemorrhoids and as- 
cites. The jugular veins are distended, but only show pulsation when 
the right auricle has hypertrophied, when we have a diastolic- presys- 
tolic pulsation, but not collapse of the veins following it unless regurgi- 
tation is also present. 

Unless the venous pulse is present inspection gives no sign distin- 
guishing this disease from the precedent mitral affection. The pulse 
is small and weak, sometimes irregular or very rapid. Babcock describes 
a case in which there was a short thumping impulse in the epigastrium, 
similar to but distinct from that of the associated mitral stenosis; also 
a short presystolic thrill between the ensiform cartilage and the left costal 
cartilage. Percussion shows the increased size of the right auricle at 
the right of the sternum. Auscultation may show a murmur, most dis- 
tinct over the ensiform cartilage, presystolic; but in practice this can rarely 
be made out in the tumult occasioned by associated disease. The altera- 
tion in the shape and size of the heart may so change its relations that 
the murmur is heard at other than the classical points. 

Dingnosis: — This is rarely made during life. The prognosis is not 
good, the disease occurring late in the history of mitral disease. Fail- 
ing compensation is not usually restored. Albuminuria and effusion 
into the serous sacs, with cyanosis and extreme dyspnea, indicate the 



390 PULMONARY LEAK 

approach of the end. But it is often a mystery to account for the pro- 
longation of life in such cases. Death generally comes from extreme 
exhaustion. 

PULMONARY LEAK 

This is a rare form of heart-disease and very rare as occurring singly. 
Babcock has observed one case. We may have relative incompetence 
from extreme dilatation, or imperfection of the valve from disease of 
the leaflets. The latter may be congenital or acquired. In relative 
insufficiency the artery and ring are stretched, the vessels atheromatous, 
the leaflets increased in length and breadth. The same inflammatory 
changes may be seen as in other valves. Sometimes the leaflets have 
been found torn into shreds from inflammatory softening. Even the 
congenital cases are rare. One should not be in a hurry to diagnose 
congenital valvular disease in infants from a murmur without other evi- 
dence. Cotton denies the possibility of accurate diagnosis between 
functional and organic murmurs in such cases. The writer has heard 
such murmurs, and found on examining the children in later years that 
the murmurs had completely disappeared, and no evidence of circulatory 
derangement remained. If structural disease really exists there is usually 
also a pervious septum or ductus arteriosus. In the acquired form the 
right ventricle becomes dilated or hypertrophied, the tricuspid valve 
becomes relatively imperfect and the symptoms of venous engorgement 
follow. Degeneration of the heart muscle ensues in due time. 

Etiology: — In the usual secondary form, the cause is abnormal ten- 
sion of the pulmonary artery, which may be due to disease of the heart 
or of the lungs. Mitral disease is therefore the usual cause, either pri- 
mary or secondary to aortic disease. Inflammation of the valve is less 
frequently rheumatic than it is septic, and is especially apt to accompany 
pneumonia or puerperal infections. 

Symptoms: — The symptoms of mitral or aortic disease precede and 
accompany and usually mask those of the pulmonary defect. The right 
ventricle probably becomes exhausted, and the tricuspid valve insufficient 
somewhat more quickly; but as there is no definite course for these maladies 
this can only be inferred. Possibly we may find a murmur with the sec- 
ond sound, heard most distinctly about the head of the third left rib. 
When the disease occurs primarily it usually remains latent, perhaps 
throughout life. 

Inspection shows nothing characteristic unless it may be a heart-im- 
pulse stronger than normal, which is due to hypertrophy of the right 
ventricle. Palpation shows epigastric pulsation due to the same cause. 



PULMONARY STENOSIS 391 

The pulse differs markedly from that of aortic regurgitation in that it does 
not show the sudden beat with rapid collapse of the latter. It is small 
and weak, the rate depending on the compensation. The enlarged right 
ventricle extends the cardiac dull area downward and to the right. Aus- 
cultation shows the presence of the murmur described above. However 
slight may be the alteration of the second sound in the pulmonary area 
it is significant. 

The diagnosis is between pulmonic and aortic disease. The murmur 
from the former is not heard to the right of the sternum, where aortic 
sounds are almost invariably audible. The other characteristics of 
aortic disease are absent. The prognosis is grave, excepting primary 
cases, where if compensation is exactly balanced the lesion has been 
known to exist for fifty years. Albuminuria and dropsy are significant. 
Death occurs from exhaustion, the last stages being long drawn out. 

PULMONARY STENOSIS 

This affection is rare as a congenital lesion, very rare as an acquired 
one. Babcock could find only eight cases of the latter reported since 
187 1. These showed traces of recent inflammation, the pulmonary 
artery usually being dilated. The valves showed vegetations or other 
deformities. In congenital cases the edges of the valves usually adhere 
and the artery is narrow. The ductus arteriosus is usually but not always 
open. Various forms of maldevelopment have been described. 

Etiology: — Congenital cases are caused by fetal endocarditis, or im- 
perfect development; cases occurring after birth are due to acute infections 
like rheumatism. 

Symptoms: — In congenital cases the patients are weakly, mentally 
and physically undeveloped and cyanotic. They usually die of phthisis. 
Many cases show no symptoms by which the disease may be suspected 
in its earlier stages; later we have debility, shortness of breath, and the 
symptoms already so often described as resulting from the interference 
with the circulation. The right ventricle becomes hypertrophied, the 
tricuspid valve in time becomes insufficient and the classical symptoms 
follow. 

Cyanosis is not only always present or uniform; it is most marked 
about the face, fingers, elbows and knees, and is worse on exertion or 
strain. It usually indicates an accompanying imperfection of the septum. 
In the acquired form the patient is pale, the superficial veins swollen, 
the right ventricle enlarged. This contributes a heave, evident on pal- 
pation, with a thrill in the pulmonic area, the second left intercostal space 



392 VALVULAR HEART LESIONS 

near the sternum. The pulse is small, weak and rapid. Percussion 
shows enlargement of the right ventricle and later of the auricle. Aus- 
cultation detectsta murmur most intense in the pulmonary area and ex- 
tending to the left; it is not transmitted to the cervical arteries. 

It accompanies the first heart sound; the second sound is weak or 
absent in the pulmonary area. 

Diagnosis: — The limitation of the murmur to the pulmonary area 
distinguishes this from the aortic lesions, while the evidence of hyper- 
trophy of the right ventricle and the history of infectious disease pre- 
ceding, usually suffice. The radial pulse is markedly affected in aortic 
disease but not in this. Cyanosis and phthisis indicate the pulmonary 
lesions. 

These patients rarely live to see thirty, falling victims to phthisis 
during early adult life. Sometimes death is directly due to the weak- 
ness of the heart. * 

DIAGNOSTIC MURMURS OF VALVULAR HEART LESIONS 

A murmur with the first heart sound, most intense at the apex, means mitral 
leakage. 

With the second sound, most intense at the apex, mitral stenosis. 

With the first sound, most intense at second intercostal space, right of sternum, 
aortic stenosis. 

With the second sound, most intense at second intercostal space, right of 
sternum, aortic leakage. 

With the first sound, most intense at second intercostal space, left of sternum, 
pulmonary stenosis. 

With the second sound, most intense at second intercostal space,, left of sternum, 
pulmonary leakage. 

With the first sound, most intense over ensiform cartilage, tricuspid leakage. 

With the second sound, most intense over ensiform cartilage, tricuspid stenosis. 

These form the alphabet of valvular heart-diseases; the exceptions 
and many useful additional data concerning each of these will be found 
in the detailed description, but this table forms the beginning which every 
clinician should firmly implant in his memory, adding whatever subse- 
quent knowledge he may obtain from time to time. Multiple lesions 
will simply present two or more of the murmurs here described. 

In interpreting the meaning of these abnormal valvular sounds or 
murmurs, it is necessary in all cases to take into account the concom- 
itant circumstances, especially the circulatory conditions. There can 
be no decided imperfection of a valve without occasioning abnor- 
mality in the distribution of the blood. An apparent pulmonary 
murmur with evidences of aortic valve disease may signify an 
abnormal position of the heart. Similar lack of correspondences 
may be detected in other cases. 



VALVULAR HEART LESIONS 393 

COMBINED VALVULAR LESIONS 

Sometimes these heart-diseases commence with one of the lesions 
of a single valve that have been described. The other valves become 
implicated by extension of the original disease or as a result of the me- 
chanical conditions involved. At other times more than one valve may 
be implicated at the onset, or we may have both narrowing and leakage 
of the same valve. 

The causes of mitral disease frequently occasion both constriction 
and insufficiency, especially in adults. There is less dilatation than 
when the leak exists alone. So also the ventricular atrophy of extreme 
obstruction, the auricular hypertrophy of the same and the auricular 
dilatation attending free leakage, are all lessened by the accompanying 
lesion. Hence, the two lesions to a certain extent relieve the symptoms 
caused by each. The development of symptoms depends upon com- 
pensation. The diagnosis is generally simple, being made by the com- 
bination of the signs of each lesion already described, the general symp- 
toms being less marked. The prognosis is also better than for either 
lesion alone for the reasons just given. 

The combination of mitral and aortic stenosis makes a serious im- 
pediment to the circulation. The left ventricle contracts, the left auricle 
and right ventricle are greatly hypertrophied. The symptoms are early 
and pronounced, the congestion of the lungs becoming extreme. Dyspnea 
is distressing, the venous trunks and roots become engorged and cyanosis 
occurs early. The pulse is very small and weak, the arterial system 
containing very little blood. The diagnosis is made by the combined 
murmurs described in previous chapters. Right ventricle hypertrophy 
develops rapidly and soon runs into dilatation. The prognosis is bad, 
the course of the disease being rapid and restoration uncertain. 

Mitral stenosis with aortic lesions may also be a serious combination. 
The left ventricle becomes hypertrophied and dilated, the same processes 
occurring in the left auricle and right ventricle. The symptoms vary 
according to the degree in which each lesion is present. Dyspnea is al- 
ways present upon exertion, especially when the mitral disease predomi- 
nates. The diagnosis is made by the signs of the two lesions, somewhat 
modified by each other. The prognosis is practically that of mitral stenosis. 

Mitral leakage with aortic obstruction is one of the most serious com- 
binations possible. The latter lesion intensifies the former. The ob- 
struction to circulation is very great; the whole heart enlarges and the 
right ventricle bears the weight of the whole circulation. The course is 
therefore a rapid one through the stages of hypertrophy, dilatation and 



394 VALVULAR HEART LESIONS 

degeneration. The symptoms are tnose of mitral disease of extreme 
character. The pulse is small and weak, the apex beat displaced down- 
ward and outward, the cardiac dullness increased in all directions. The 
two characteristic murmurs may be heard at the apex and in the aortic 
area. The prognosis is grave, the course rapid, compensation failing ©arly 
and treatment being of less avail than in most varieties. 

Aortic and mitral leakage combined occur in the late stages of aortic 
disease. It is less serious than the variety just described, the mitral 
leakage moderating the effect of the aortic. Still the arteries have too 
little blood, the pulmonary and venous systems being engorged. The 
heart is enormously enlarged; the right ventricle sustains the circulation. 
The pulse is small and collapsing, while auscultation reveals the two 
characteristic murmurs. The prognosis is better than usual, as com- 
pensation may remain for a long period. When once broken there is 
little chance of restoration. When the mitral leak occurs from relative 
insufficiency it marks a serious stage of the malady. 

Babcock believes that aortic stenosis and leakage are less frequent 
than is believed by those who depend upon the murmurs alone to es- 
tablish a diagnosis. Without the accompanying indications described 
these murmurs may signify simply irregular vibrations of the valve leaflets. 
The symptoms depend upon which element predominates; leakage may 
be compensated for many years; stenosis less likely. The ventricle 
dilates and dyspnea with palpitation occurs after slight exertion, more 
than would be the case with either lesion alone. The pulse is smaller 
and its collapse less marked than in aortic leakage alone, larger and more 
rapid than in stenosis alone. The heart's impulse is weaker than in leak- 
age alone and the dullness indicates less enlargement. A systolic thrill 
may be felt in the aortic area. The diagnosis is difficult, often impossible 
as the distinguishing signs of each lesion are modified to some extent 
by the presence of the other. If stenosis predominates we have a slow, 
small, collapsing pulse, strongly circumscribed, not greatly displaced apex 
impulse, systolic aortic thrill and bruit, without powerfully throbbing 
and thrilling cervical arteries, no double femoral souffle or capillary pulse 
but a regurgitating murmur. The prognosis is not good. When compen- 
sation once fails it is reestablished with great difficulty. 

GENERAL PROGNOSIS 

The course of a valvular heart disease will depend upon the lesion, 
its immediate and ulterior effects and the personal condition of the case. 

Stenosis is usually more serious than leakage but the degree affects 
the result. The most serious of all the lesions is aortic leakage. In 



VALVULAR HEART LESIONS 395 

the young compensation is more likely to prolong life indefinitely. In 
the aged the sclerosis is more general and compensation is brief and par- 
tial. Sudden death is especially liable to occur in this condition. Inter- 
current rheumatism may also impair compensation which is very difficult 
to restore. 

Aortic stenosis is less serious. The hypertrophy does not give way 
to dilatation unless the obstruction is very great. Compensation once 
broken is not likely to be repaired. Extreme stenosis is even more serious 
than extreme leakage and the combination of the two is still graver. The 
ingenuity of the physician may be taxed in their management. 

Mitral stenosis is more ominous than mitral leakage; the former 
increasing from the continuance of the original disease and the deposit 
of fibrin. Mitral leakage admits of a better prognosis than any of the 
three other affections of the left heart. If not too free and uncomplicated, 
life may be prolonged with activity to the full expectancy. Sudden death 
is quite rare. 

Tricuspid leakage is an incident in the history of mitral disease and 
enough has been said concerning it. The other affections of the right 
heart are too rare to require special discussion. 

The prognosis, therefore, depends much more upon the seriousness 
of a lesion than upon its presence. The degree to which the circulation 
is sustained by compensation is an important factor. If the compensating 
conditions are sufficient and remain at a standstill the prognosis is good. 
Complications, intercurrent acute maladies, renewed attacks of rheuma- 
tism, embarrassing adhesions, constitutional disease of the kidneys, etc., 
phthisis, anemia, digestive disorders, old age or very young age, tempera- 
ment in which we may include tractability and the possession of common 
sense, each influence the prognosis. Women are more subject to mitral 
disease, men to aortic leakage. The occupation is an important factor, 
strong exertion shortening compensation. The habits of overeating, 
indulgence in tobacco, alcohol, other habit drugs, and sexually, with bad 
hygienic habits generally, exert an evil influence; unsanitary hygienic 
conditions all work far more harm in these cases than in ordinary individuals. 
The knowledge that a patient has a defective heart is usually beneficial, 
as he may thereby be more easily induced to so regulate his life as best 
to delay the progress of the malady. Some persons, however, are fright- 
ened into hypochondria, insanity or even suicide by such information. A 
most important element in the prognosis is to be found in the comprehen- 
sion by the patient's physician of the true value and applicability of heart 
tonics and other means of treatment, as well as their special applicability 
in each particular case. 



396 VALVULAR HEART LESIONS 

The foregoing considerations should suffice to guide the physician 
in examination for life insurance. Babcock advises to reject cases of 
pronounced mitral stenosis and aortic leakage and considers mitral leak- 
age and moderate aortic stenosis reasonable risks. The considerations 
just described, however, show the impossibility of determining such a 
matter on the presence of the valvular defect alone. 

TREATMENT OF VALVULAR DISEASE 

We will first consider those cases in which compensation has been 
established, and the circulation is maintained in a fairly normal condition, 
nothing having occurred to direct the patient's attention to his imper- 
fection. Even severe bodily exertion does not occasion dyspnea or palpi- 
tation more than with persons whose hearts are unaffected. When com- 
pensation is incomplete severe exertion causes evident distress. When 
compensation has been lost physical exertion becomes impossible and even 
when at rest the engorgement of the veins, with dropsy and other symp- 
toms, are manifest. 

No secondary circulatory effects are evident with perfect compensa- 
tion. The same restrictions are therefore not necessary, as in the other 
two classes. Our duty consists in prescribing such a mode of life as will 
longest sustain the circulatory equilibrium thus happily established. 
It is unnecessary to acquaint the patient with the existence of the lesion 
unless his mode of life be such that he is likely to be injured by it, es- 
pecially if he is unduly nervous or apprehensive. In the vast majority 
of cases, however, a knowledge of the existence of such a lesion is the 
most important element in holding the patient in due restraint. This is 
a case where the physician must dominate, or retire from the case. 

Physkdl Exertion: — The occupation should be such as will sustain 
the patient in good health without throwing an undue strain upon the 
heart or his general muscular system. Mitral disease requires restraint 
in this particular unless very slight. Dyspnea should be the signal for 
physical rest. The amount of exercise required will in every case depend 
upon the physician's study of the case and the effects of the exercise. 

The same rules apply to a case of mitral stenosis. Palpitation indi- 
cates that too much exercise has been taken. 

In mitral leakage compensation is never absolute but only relative, 
because engorgement of the lungs is necessitated by the right ventricle 
hypertrophy on which compensation depends. Slight lesions may be 
disregarded. Rheumatic cases bear exercise better than the sclerotic 
form. Palpitation or dyspnea must still be avoided but exercise short 
of producing these symptoms is permissible. The muscular development 



VALVULAR HEART LESIONS 397 

and the habits will influence each case. Mountain climbing is especially 
to be avoided. 

Aortic leakage allows more exercise than any other form of heart 
disease, except in the sclerotic form; in fact, Stokes used to order severe 
exercise for such patients with a view of developing left ventricle hyper- 
trophy when insufficient. Nevertheless, care must be taken that the 
exercise does not cause hypertrophy in excess of the need. 

After the fortieth year arteriosclerosis and other degenerative processes 
become more frequent and closer limit should be placed upon the physical 
exertion permissible. However, these patients must not be allowed to 
sink into sedentary habits. Moderation in exercise does not mean its 
entire disuse. 

The occupation permissible for such patients depends upon the prin- 
cipled just established as to exercise. Straining of every description and 
long-continued severe exertion are objectionable. The inhalation of dust 
is especially injurious to persons with congested lungs. Exposure to bad 
weather and sudden changes of temperature are bad for these persons, 
who catch cold easily and with whom catarrhs are obstinate. Indoor 
and mental work is recommended by Babcock for mitral patients and 
those with serious aortic lesions; outdoor work for compensated aortic 
leakage, slight aortic stenosis and some mitral leakages. 

All excesses are injurious; sexual indulgence especially. Serious 
failure of compensation in either sex is apt to follow r marriage. The use 
of tobacco is always injurious although if the habit has been formed, 
compensation perfect, and the patient can be trusted to use the drug with 
moderation, it may not do perceptible harm for some years. Tobacco 
smoke always increases the bronchial irritation and anemia. MacKenzie 
used to forbid tobacco to those with whom it induced salivation and fre- 
quent spitting. 

An alcoholic debauch is always capable of destroying compensation. 
There is no need for alcohol in these cases and its effect can never be 
exerted upon the diseased heart beneficially, while in most cases its use 
is productive of injury, in any form or quantity. 

Marriage is to be advised for persons with compensated heart-lesions 
only when the influence of unrestricted indulgence has been explained 
and the patient thoroughly comprehends what is to him normal and harm- 
less indulgence. As to the wife, we have also to take into consideration 
the comforts to be secured in the home to which she goes, and the intelli- 
gence and consideration of the husband to whom she entrusts her life. 
Pregnancy and childbearing are often withstood by such women without 
serious harm. Nevertheless, the question is one of the gravest in every 



398 VALVULAR HEART LESIONS 

such case. Women with mitral disease should not marry, as no woman 
has a right to marry whose physical condition is such as to render it in- 
advisable that she should endure the perils of pregnancy and childbearing. 
When such a woman, however, marries and becomes pregnant, she will 
require care on the part of the physician throughout her whole term of 
pregnancy. The venous engorgement must be kept in check by saline 
laxatives, passive exercise by massage' alone permitted, but this must be 
enjoined, the diet should be most carefully regulated; and when labor 
occurs delivery by instruments under chloroform secured at the earliest 
possible moment. Aortic disease is less serious, nevertheless Davis found 
that more than 50 per cent of mitral and 23 per cent of aortic cases suc- 
cumb to the dangers of pregnancy and gestation. 

Babcock sums up the matter by stating that pregnancy is a grave con- 
dition not necessarily perilous to these cases. Labor is a real danger, in 
mitral disease especially so, the degree depending upon the compensation 
and other conditions present. Special care is required as labor approaches, 
with early instrumental deliverance. The dangers of the marriage should 
be clearly set forth to both parties and they should be advised frankly 
not to marry. If compensation is imperfect, pregnancy should be inter- 
fered with only when compensation cannot be maintained or when serious 
symptoms have already supervened. 

The question of clothing is of importance. Changes in temperature, 
etc., have an effect upon the tension of the circulation which is of much 
more importance than with normal individuals. Care should, therefore, 
be taken by all such patients to avoid the effects of these changes, by 
wearing woolens next to the skin, keeping the hands and feet warm during 
cold weather, especially protecting the feet against dampness, and having 
the clothing too loose to constrict superficial vessels. A tight undervest 
is as bad as a tight corset. Women's skirts should be suspended from 
the shoulders and not from the waist. 

Prolonged hot baths relax vascular tension and weaken the heart, 
especially with mitral cases. In all cases, however, bathing should be 
regulated by its effects on the patient. Swimming is in many cases a 
dangerous pastime. Turkish baths should not be permitted unless the 
physician is present and observes their effects. In general, "rag" baths 
with rubbing are preferable to tubbing. 

Diet: — In no class of maladies is the question of diet more important. 
This may be best comprehended by a consideration of the mechanical 
conditions presented in the circulation. The heart is a force pump whose 
duty is to project the blood through the circulation. It is obvious that 
the greater the bulk of the blood the greater is the task thrown upon the 



VALVULAR HEART LESIONS 399 

heart. Every lesion of the valves throws an additional burden upon the 
heart, inducing first hypertrophy and following it the entire list of lesions 
described. It seems obvious, therefore, that the first indication in the 
treatment of all valvular diseases of the heart is to reduce the work of 
this organ to the lowest point compatible with the maintenance of health. 
It is obvious that this can be done by reducing the bulk of the blood, 
provided we can retain in a smaller quantity of the fluid the full amount 
of nutritive material existing in it when expanded with water. This 
indication can be met by putting the patient upon a carefully balanced 
ration. The solid constituents of the food should be so arranged as to 
give the patient the exact quantity of proteids, carbohydrates, fats, salts 
and water, which he requires to sustain his activity at the desirable point, 
and not a grain more. Especially is it desirable to rid the patient of super- 
fluous and encumbering fat, which may be done quite agreeably by re- 
stricting the quantity of w r ater, and by massage or other appropriate forms 
of exercise. The same thing may be said in regard to the presence of 
anemia or of plethora. These conditions call for such a regulation of 
the foods as will restore normal conditions. 

Every intercurrent disease must be promptly treated, with the utmost 
care, as the consequences are liable to be far more serious than they would 
be for normal individuals. In children especially rheumatism must 
be detected even if it only appears in the form of a sore-throat or a chorea, 
or even a cold in the head. Every pains must be taken to prevent respira- 
tory catarrhs becoming chronic. Infections are to be avoided or if in- 
evitable, treated promptly and effectually, most assuredly not on the 
expectant plan. 

Drugs are to be used only to fulfill distinct specific indications. The 
man who only knows that digitalis is good for heart-disease, if he still 
exists, should be encouraged to find some other employment than the 
practice of medicine. In fact, during the period of compensation, while 
the greatest stress is to be laid upon the hygienic regime, there is little 
occasion for any drug excepting for intercurrent conditions. Among 
these constipation and flatulence are not to be neglected. 

It is difficult to overestimate the evil effects of autotoxemia. On 
this subject Babcock says: "Two conditions likely to prove more in- 
jurious to individuals with a valve lesion although compensated than 
would be the case if his valves had not been damaged, are constipation 
and flatulent distention of the bowel. In both splanchnic irritation and 
consequent alteration of blood-pressure, but in the latter the effect of 
mechanical encroachment upon the contents of the thoracic cavity, must 
be reckoned with. Uncorrected it mav contribute materia 11 v to the 



4 oo VALVULAR HEART LESIONS 

destruction of heart-adequacy, to say nothing about the patient's dis- 
comfort in the way of post-prandial breathlessness in mitral and tendency - 
to palpitation in aortic disease. Both disorders of the digestive function 
tend to impair the appetite, give rise to neuralgias, anemia, coldness of 
the extremities and many other phenomena of autoinfection. Moreover, 
flatulent indigestion, probably through the absorption of toxins, is a fre- 
quent cause of deranged cardiac rhythm. This not only annoys or even 
alarms the patient but it may even lead to the development of dilatation." 

Hence the treatment of these intestinal conditions is most essential. 
An evening dose of podophyllotoxin with a morning dose of saline and 
a sufficiency of intestinal antiseptics meet the difficulty. The heart- 
tonics are not to be used unless the digestive affections occasion tem- 
porary disorder, in which case cactin is the best remedy to steady the 
heart, while glonoin relieves palpitation or vertigo; the two may be taken 
together. Digitalin should be saved for more serious conditions. Rest 
is more essential than drugs. 

Climate: — Some patients do better in elevated regions than near the 
sea level; with others a heart-lesion hitherto unsuspected is apt to develop 
on ascending a few thousand feet. Babcock finds patients with mitral 
or aortic stenosis and mitral leakage with adhesions endure high altitudes 
badly. The amount of exercise taken, however, is of importance. Pa- 
tients first going to high altitudes should strictly confine their exercise 
to such as can be taken without dyspnea or other inconvenience. Until 
they have ascertained what the general effect of the altitude is going to 
be, the less exercise the better. . • 

The cases in which the writer has observed the development of heart- 
lesions in the mountains have been in elderly persons with sclerosis. This, 
however may be an exceptional experience. 

Treatment When Compensation is Imperfect:- -The causes of the 

failure of compensation must be carefully considered and remedied as 
far as may be possible. The hygiene of the case requires the most minute 
regulation, the habits need the most exact surveillance. Every unfavor- 
able influence that can be removed aids in delaying the progress of the 
malady and in prolonging the patient's life. It is often advisable to 
inaugurate treatment by a term of absolute rest in bed, with massage, 
until decided improvement has occurred. The diet, solid and fluid, 
should also be closely restricted until we are able to determine the quantity 
of each the patient can take with advantage and manage successfully. 
After this, additions to the exercise and the diet are to be made gradually 
and under close watch, that no excess be permitted to cause a setback. 
Any intercurrent affection must receive prompt and effective treatment. 



VALVULAR HEART LESIONS 401 

The digestion may be sedulously cared for, constipation prevented, 
artificial digestants employed freely if needed, and business and other 
annoyances excluded. 

The question of the use of the heart tonics is an exceedingly nice one, 
but perfectly comprehensible if the mechanical conditions involved are 
understood. Digitalis contains at least, four active principles of varying 
powers. Digitoxin is the most powerful as a heart-tonic and still more 
as a contracter of the arterioles. The latter power causes it to increase 
the work of the heart by lessening the lumen of the outlets through which 
the blood must be forced; and also endangers the patient by so contract- 
ing the renal artery as to check or even completely suppress the excretion 
of urine. Besides, the action of digitoxin is so slow that Fraenkel, ad- 
ministering it hypodermically to a cat, found that the effects were not 
manifested until the expiration of 60 hours. Digitoxin is also insoluble 
in water. Digitalin is a doubtful principle, probably consisting of a mix- 
ture of several, in varying proportions. It is more soluble than digitoxin, 
but required 30 hours for its effects to be manifested, in Fraenkel's ex- 
periments. The preparation known as Germanic digitalin is really dig- 
italein. It is freely soluble in water, and its effects are evident within 
half an hour after administration. It has all the heart-tonic power of 
the drug, with a minimum of the contractile effect upon the vessels. It 
acts as a diuretic only by restoring vascular and cardiac tone when deficient, 
and hence is not in this respect or any other synergistic with digitonin, 
which depresses the power of the heart and acts as a diuretic only by 
relaxing excessive vascular tension, such as is produced by digitoxin. 
The idea that a union of digitalein and digitonin would secure the 
maximum diuretic effect of digitalis is therefore an error. The effect 
of such a mixture would be that of the predominant ingredient, 
minus the other one. From these considerations it seems clear that 
the safest and most effective manner of utilizing digitalis is to admin- 
ister only the pure digitalein, or Germanic digitalin as it is com- 
mercially entitled. 

While the effects of this glucoside are uniform as to quality and quantity 
of action, the conditions presented by the patient vary widely. The 
solubility and quick action of this principle enable us to administer small 
doses in rapid succession until we have secured exactly the effect we 
desire; after which smaller doses may be employed to sustain this effect. 
The writer gives digitalin Germanic, gr. 1-67 in hot water, preferably 
allowing it to be absorbed from the mucous membrane of the mouth, 
and repeats this dose every half hour to two hours, until the pulse has 
been restored to normal tension. 



402 VALVULAR HEART LESIONS 

We look to the pulse rather than to the heart for the indication of 
digitalin effect. Relaxation of the circulation itself constitutes an obstacle 
which the heart is compelled to overcome; if arterial tension is exactly 
restored to normal, this obstacle is removed and the heart's work facili- 
tated. The circulatory swamp is thus canalized. But if any excess 
is given the arteries are unduly contracted and this offers another ob- 
stacle for the heart to overcome. There is perhaps no instance in the 
field of medical practice where the nicest balancing of therapeutic action 
to the needs is so absolutely essential as here. Too little fails, too much 
injures. Not only so, but too large doses tend to restrict the elimination 
by the kidneys, and to wear out the reserve forces of the heart by over- 
stimulation and by adding another burden. The value of this nice regu- 
lation of the dose may be seen in cases where the circulatory balance thus 
obtained has been sustained for years by the daily use of digitalein. The 
heart's powers are thus conserved and its nutrition enhanced, so that 
an actual material improvement in the conditions is secured, instead of 
a simple temporary check given to the disease. 

Whatever dose of digitalin may be required to attain such balance is to 
be given. It may require gr. 1-4 three times a day, or even more, and if so 
such doses are to be given fearlessly. Usually, gr. 1-12 three times a day 
suffices, and after a few days this may be gradually reduced to about gr. 
1-20, twice a day, which will be found an average for continuous use. 

Digitalin is the remedy conspicuously for mitral lesions. If the phy- 
sician clings to the galenic preparations he had better confine himself 
to digitalis and eschew all the other heart-tonics, because he is scarcely 
likely to obtain any of the others in as good quality. Digitalis is used 
more than all the other cardiac tonics many times over, and the phy- 
sician's chances of obtaining a good and recent preparation are much 
better than when he prescribes adonis, convallaria, or other seldom 
employed articles. 

The case is different to those who prefer the active principles. These 
glucosides when made into granules with pure sugar of milk will keep 
for an indefinite number of years without change, and the nice discrimi- 
nation they allow may then be utilized. 

In sclerotic cases, when the arteries are rigid and the constricting 
effect of digitalis would be dangerous, there is but little danger in the 
administration of Germanic digitalin. This little may be obviated by 
the conjoint use of veratrine. It is usual for glonoin to be advised here. 
The effects of the latter are manifest within half a minute of its adminis- 
tration in solution, by the mouth, and rarely do these effects last more 
than five minutes. Under no circumstances are the powers of any dig- 



VALVULAR HEART LESIONS 403 

italis derivative recognizable until the expiration of a much longer time; 
even digitalein begins in half an hour or a little less, and continues for 
four to six hours. The conjoined administration of this and glonoin 
is far from securing simultaneous action. With veratrine it is different. 
Given in doses of gr. 1-134 x in solution, its effect begins about as soon 
as that of digitalein, and continues even longer. The effect of these 
small doses on the heart muscles is tonic, on the arteries relaxant; in 
both ways it enhances the action of digitalein, and the two further agree 
in stimulating cardiac inhibition. The further action of veratrine in 
favoring elimination may cr may not be desirable — in the vast majority 
of cases it is most desirable. But if veratrine causes irritation of a ca- 
tarrhal stomach, as denoted by a sense of warmth outlining the walls 
of this viscus, aconitine should be substituted in the same dosage. In 
aortic disease, where the constrictor effects of digitalis are mere ob- 
jectionable than in mitral cases, strophanthin is preferable. This exerts 
a powerful cardiac tonic action with the minimum cf arteriole constric- 
tion. In sclerotic cases also, and when veratrine irritates the stomach, 
strophanthin may replace digitalin. The strophanthins in the market 
vary so widely in strength that the practician who desires to use this glu- 
coside should select one reliable make and adhere to it. The tinctures 
vary as widely and in addition the strength of any sample varies from 
day to day. Of strophanthin, standard quality, gr. 1-500 may be given, 
in hot solution on the tongue, every half-hour till the effect is manifest. 
The daily dose thus established for that case may be then concentrated 

into three or four doses a day, as desirable. 

> 

The place of strychnine is not clearly comprehended. It is a uni- 
versal incitor of function, but its stimulation of the inhibitory nerve and 
vasomotor contractors is less pronounced than its direct tonic action on 
the heart. It therefore comes in as an alternant with digitalin, or better, 
may be given simultaneously to enhance the effects of the latter. Dosage 
must be strictly for effect, and Babcock therefore speaks of giving gr. 
1-30 every two hours, eight doses a day, continued for weeks with no 
harm but positive benefit. Curtin, however, holds that large doses are 
likely to cause short and irritable systoles instead cf the long, strong 
ventricular contractions of digitalin. In any event, the maximal doses 
here mentioned are only applicable to cases of advanced disease with 
serious failure of the circulation. In many instances the weaker tonics 
are better suited to the task of inducing just the degree cf stimulation 
that is needed and no more. This is where cactus is so useful. Some- 
times a mere fraction of a drop of the tincture suffices. Its use in doses 
larger than five drops twice a day is not advisable. 



4 o4 VALVULAR HEART LESIONS 

Convallamarin is said to be especially valuable when it is desirable 
to stimulate the right ventricle rather than the left. 

Apocynin is especially suitable when dropsy is a marked feature. 
This drug acts also upon the liver and in full doses is a cathartic. Its 
use is therefore indicated when the vascular tensor power of digitalin 
is insufficient. Apocynin is here next to digitoxin in effect but is a safer 
remedy and its action is more speedily exerted. The average adult dose 
is from gr. 1-12 to 1-6, repeated every four hours and carefully in- 
creased until the full effect is manifested by nausea or catharsis. 

Pettey, who has had unusual opportunities for observing the action 
of drugs, and has utilized these opportunities with unusual care, states 
that in some instances when digitalis has been given until worn out, he 
has rescued the patient from impending death by the hypodermic use 
of sparteine in doses of 2 gr. each. Smaller doses did not give the effects. 
In many instances when moderate doses of digitalin seem to lose their 
effect better results will be obtained by adding the other heart-tonics 
in succession, rather than by increasing the dose of any one of them. If, 
as seems probable, each of these drugs exert its maximum influence upon 
a different portion of the cardiac mechanism it is easy to be seen why 
this should be. In this manner, to the cardiac tonics above named we 
may add adonidin, barium chloride, erythrophloeine and other mem- 
bers of this group. 

For vertigo, syncope, to momentarily combat cerebral anemia or re- 
lax an embarrassing tension, glonoin is the remedy. This drug exerts 
a quicker action when given by the mouth than hypodermically. Give 
gr. 1-250 in solution or let the patient chew the granule, and repeat every 
five minutes until the face flushes. When thus employed glonoin de- 
serves the title given it by enthusiastic admirers of the "life saver." 

Most writers on the treatment of heart-diseases recognize the great 
value of cathartics, but few explain the benefit correctly. The heart is 
always relieved by a reduction in the bulk of the blood, and if no better 
means were available to secure this benefit, a venesection might in some 
cases save life for the time being. But in addition the cathartic clears 
out toxic matter from the alimentary canal and encourages exosmosis 
from the blood to the bowel instead of the reverse which is so apt to occur. 
It is an object, therefore, not only to empty the bowels but to flush them, 
and for this purpose there is nothing better than a dose of calomel or 
podophyllotoxin at bedtime, followed by a saline immediately on rising. 
If conditions are such as to forbid the bulky saline solution we may inject 
into the colon or rectum a few ounces of glycerin or of a saturated solution 
of table salt. 



VALVULAR HEART LESIONS 405 

It is of importance to watch carefully the condition of the patient's 
blood and meet any drain upon it by the administration of such tonics 
as may be needed, either iron, quinine, arsenic, the hypophosphites or 
manganese. Whichever of these is used a' better effect will be obtained 
from the simultaneous administration of nuciein. This remedy seems 
to enable the body to retain iron and other nutritive products which would 
otherwise pass through. 

Sometimes it is difficult to rid the patient of the pernicious idea that 
he must take exercise to restore his strength. The moral effects of a 
little massage may here be utilized with great advantage. In general it 
may be said that whenever compensation begins to fail the necessary 
work performed by the heart should be reduced to the lowest possible 
point until compensation is reestablished, after which no more work can 
be allowed than such as will not disturb this desirable condition. The 
regulation of such exercises requires as great precision and watchfulness 
as the regulation of the diet. Massage, resistance exercises and other 
movements performed under the eye of a competent director, should 
precede walking and other forms entrusted to the patient. 

Of late years the Nauheim baths have attracted considerable attention 
as a means of treating heart-diseases. The waters at this resort contain 
the chlorides of sodium and lime and are highly charged with carbonic 
acid. At first baths are administered at a temperature of 95 F., the 
water containing 1 per cent of sodium chloride and 1-10 per cent of cal- 
cium chloride; the first bath lasts five to eight minutes; the baths are 
repeated daily with occasional omissions; the temperature being gradually 
lowered and the strength of the mineral constituents increased, the exact 
formula being regulated by the strength and reaction of the patient. At 
the maximum the percentage of chloride of sodium is 3, the calcium salt 1, 
the temperature 85 F. and the duration twenty minutes. Usually this 
is reached in three to four weeks. When the baths prove beneficial they 
render the pulse slower and stronger as well as more regular. The size 
of the heart diminishes while its sounds are stronger. Benefit is judged 
largely by the reduced size of the heart and its return to normal action. 
There is also a sense of improvement in the subjective symptoms. The 
benefit often experienced is remarkable, in fact some stress has been 
placed upon the pathologists to explain this benefit, but as the method 
originates in Germany, not America, and does not consist in the administra- 
tion of drugs, an explanation of the benefit is sought, rather than a denial 
made of its existence. 

The Nauheim system has been employed in America, especially by 
Dr. Babcock, and the results fully equal those obtained in Germany when 



4 o6 VALVULAR HEART LESIONS 

the same favorable conditions have been secured. It is obvious that the 
best results are obtained when the patient leaves his business and all en- 
vironing irritations and devotes himself seriously to the business of his 
treatment. The method is unsuited to cases in which compensation is 
altogether lost, and to those presenting extensive arteriosclerosis, dropsy 
or adhesions, with degenerated heart-muscle. If the pulse does not show 
improvement after the bath, it is not doing good. 

We have already discussed the subject of diet, as to the bulk of the 
food and especially as to the quantity of water which is permissible. The 
rations should be carefully balanced so as to contain the exact proportion 
of each food element required; the articles should be such as are digested 
easily with little residue. Flatulent articles like beans are to be forbidden. 
The tendency in these cases is to the excessive use of proteids with conse- 
quent toxemia. Flatulence from carbohydrates may be prevented by 
the use of some form of diastase. Flatulence of any sort is relieved by the 
administration of physostigmine. When degeneration of the heart- 
muscle is threatened, the proportion of meats should be increased, espe- 
cially in the shape of eggs, fish and oysters, with milk. In all cases eating 
should be confined to the regular meal-hours and food between meals 
forbidden. The fresh fruit-juices must never be omitted. Such patients 
are often tormented by thirst, which may be relieved by chewing gum, 
or by giving a teaspoonful of hot water at intervals of 15 to 30 minutes. 
Patients who are constantly tormenting the nurse for drinks will wait 
contentedly, watching the clock, if they know they are to get something 
in a reasonably short time. 

The exclusive milk diet is sometimes advisable, especially when dis- 
ease of the kidneys is present. In general, the hygienic precautions de- 
scribed in the preceding chapter are applicable here. Especially we must 
emphasize the importance of avoiding alcohol and tobacco, emotional 
excitement, muscular strain, sexual and other excesses, 

TREATMENT OF BROKEN COMPENSATION 

In some cases, despite all our efforts, and in many others for lack of 
intelligent management, the patient arrives at a stage where compensation 
is not simply weakened but is broken or lost. It is here especially that 
we become acquainted with the immense power for good residing in 
digitalin, when intelligently employed. The careful physician has held 
this powerful weapon in reserve and therefore now obtains its full benefit. 
Here is an illustrative case: The writer was called to attend a woman, 
aged over 40, supposed to be dying of pulmonary consumption. She had 



VALVULAR HEART LESIONS 407 

just had a severe bronchial hemorrhage, not the first one, and her history 
showed that she had been spitting blood for years. The legs were greatly 
swollen, the abdominal cavity contained some effusion, the urine was 
scanty and albuminous. Chronic bronchial catarrh existed with dyspnea 
and the lips showed the mulberry stain. The superficial veins were en- 
gorged. The primary disease appeared to have been mitral leakage, 
but she now showed a double mitral murmur with some implication of 
the aortic valve. This woman was placed upon digitalis and the hygienic 
regime herein advised. Improvement was not long delayed; she got up 
from bed in a few weeks and regained such activity as enabled her to at- 
tend to her household duties, attend church, go to market, and participate 
in the social pleasures of her class. This patient remained under my charge, 
enjoying the degree of health just described, for ten years, at the end of 
which time she died of cancer of the liver. This case is typical of a num- 
ber, enough, in fact, to convince the writer that even after compensation 
has presented such serious impairment as has been described, a con- 
firmed valvular lesion may be so managed as to enable the patient to live 
to the full period of his or her expectancy in the enjoyment of reasonable 
comfort and usefulness. 

Little is to be added to the remarKS already made upon treatment. 
Begin with absolute rest in bed, so arrange the diet as to reduce the bulk 
of the blood, relieve the heart of its overwork and thus stop its rapid ex- 
haustion, meanwhile maintaining the nutrition at the highest possible 
point and aid the heart with a sufficiency of digitalin. In the case de- 
scribed, the bronchial hemorrhage was undoubtedly beneficial, but not 
more so than would have been the abstraction of an equal bulk of blood- 
serum by any other means. Here we must again call attention to the 
great value of the small enema of cold saturated salt solution. 

When the serous cavities become distended with effusion it may be 
necessary to remove a small quantity, not exceeding a pint, to relieve 
the heart from embarrassment; the effusion will, however, be quickly 
reproduced; it is generally better to give apocynin with the salt enemas 
and seek to prevent the reproduction of the dropsy by close limitation of 
the fluids ingested. Diuretics act better after the bowels have been emptied 
by calomel and salines. Multiple punctures with a needle remove a vast 
amount of water from the tensely swollen limbs, but are not very popular 
with the patient. Sou they 's tubes do better; the writer has repeatedly 
employed these to drain the abdominal cavity with excellent effect, al- 
though in a few days the internal opening is occluded by an accumulation 
of lymph. Elastic stockings and bandages aid in restraining the tendency 
to effusion. Generally, diuretics act better after the removal of an effu- 



4 o8 ACUTE MYOCARDITIS 

sion by tapping. Cathartics are not as depressing as is usually taught. 
During the treatment of extensive dropsy I prefer to rely upon apocynin 
and to omit digitalin until after the dropsy has been reduced, when this 
priceless medicament will show more decidedly beneficial effects. 

To relieve the so-called cardiac asthma no remedy in the writer's hands 
has given really decided benefit excepting strychnine arsenate. With 
proper hygienic regime and accessory treatment very small doses of this 
salt suffice, such as gr. 1-134 three times a day. But cases have been 
reported in which the daily dose reached 1-3 or 1-2 a grain with satis- 
factory results. Temporary relief occasionally follows small doses of 
morphine, but as a rule it is best omitted. Digitalin is a better hypnotic, 
producing that circulatory equilibrium which conduces to sleep. 

ACUTE MYOCARDITIS 

This affection occurs in connection with acute infectious fevers. The 
disease may be parenchymatous or interstitial. The tissues are pale and 
opaque, soft, relaxed' and easily torn; the fibers are swollen, the protoplasm 
granular, the striae obscure; the fibers are frequently ruptured or torn apart. 

The interstitial form may be purulent; the abscesses may break into 
the heart, the pericardium, or both; if into the blood-stream, pyemia and 
septic embolism follow. 

Etiology: — The acute form occurs with diphtheria, typhoid fever, the 
eruptive fevers, gonorrhea and rheumatism. The intensity of the poison 
is more likely to cause myocarditis than its long continuance. Ulcerative 
endocarditis may extend to the heart-muscle, or septic emboli may enter 
"the coronary artery. Microorganisms also enter by undetected channels. 
Sometimes the disease follows injuries. 

Symptoms: — In diphtheria myocarditis develops late. It is indicated 
as to its presence and extent by weakness of the heart. The same is true 
of the malady when occurring during other infectious diseases. The 
liver may be engorged and the seat of pain. Venous engorgement and 
dropsy, with scanty albuminous urjne, are present in extreme cases. 
There is then a sense of oppression, and pain under the sternum. 

Death may ensue within two days, or not for two weeks; the malady 
is sometimes latent. Intervals of well-being may alternate with alarming 
crises. Very dangerous are the cases which develop during convalescence 
from diphtheria. 

Rheumatic cases occur in hearts already diseased, the extension being 
inferred from the debility. In other infective fevers sudden weakening 
of the heart may be due to toxemia or to myocarditis. 



CHRONIC MYOCARDITIS 409 

The formation of pus is denoted by rigors, pyemic fever, sweating 
and swelling of the spleen. Rupture of the heart is quickly followed by 
collapse and death. 

Physical Signs: — Pallor is marked, with apathy or anxiety; the pulse 
weak, empty and unstable; the heart impulse feeble or absent; there 
may be an increase in the area of cardiac dullness; the heart sounds are 
feeble and muffled, with the murmurs of accompanying disease. 

The diagnosis is inferential; when during an acute infectious disease 
the heart suddenly fails, with the physical signs above noted and evidences 
of sepsis following, myocarditis may be assumed. 

Prognosis: This is always grave, especially in the purulent form. 
In diphtheria the mortality is about thirty-three per cent. In rheumatic 
cases the prognosis is better. In any form death may occur suddenly. 
Weakness, rapidity and irregularity of the heart are proportionally grave. 
Delirium is a bad omen; embolism still worse. 

Absolute rest is to be enjoined. The food should be highly nutritious, 
and easily digested or predigested. The bowels must be kept clear. 
The heart must be sustained by tonics but vascular tensors avoided. Stro- 
phanthin, sparteine and cactin are preferable to digitalin. On no ac- 
count should digitoxin be given; small doses of morphine may be employed 
to quiet pain and restlessness. It is frequently dangerous for the patient 
to lift his head from the pillow; while rising from the bed to urinate is 
fraught with the utmost peril. Confinement to bed must be prolonged 
for some time after the attack has subsided, and even then for a consider- 
able period the patient must not be permitted to put any strain upon the 
heart, such as is caused by ascending stairs. 

CHRONIC MYOCARDITIS 

Fibroid degeneration occurs in the late stages of acute maladies. It 
may attend extreme fatty degeneration and be progressive. Section 
shows gray streaks and spots, slightly projecting. Atrophy of the muscle 
fibers precedes the fibrous hyperplasia. The wall may be thickened, 
or giving way it may permit the formation of a cardiac aneurism. Fatty 
degeneration causes pallor of the surface. The markings have been com- 
pared to a faded leaf; the tissue is soft and fragile. The protoplasm 
breaks down and fat drops appear. In the advanced stages, the fatty 
fibers are replaced by fibrous tissue. 

In old age we have a mixture of fatty and fibrinous degeneration, with 
fatty overgrowth in the obese. Sometimes there is hypertrophy, with 
nephritis and atheroma; or atrophy with malnutrition, or pigmentation. 



4 io CHRONIC MYOCARDITIS 

Innutrition results from disease of the coronary arteries by which the 
supply of nutritive blood to the heart tissues is lessened. 

Etiology: — Arterial disease, nephritis, hard labor, long marches, 
mountain climbing, excessive beer-drinking, toxemias, poor heart-nutri- 
tion, phosphorus, arsenic, cardiac hypertrophy, abuse of coffee, tobacco 
or alcohol, are the causes. It most frequently affects men. 

Symptoms: — The malady affects strong, middle-aged men, brain 
workers of sedentary habits and large eaters and drinkers. The pulse 
may be normal, the signs negative except that the second aortic sound 
is accentuated, the superficial arteries stiff, the urine low in gravity. There 
may be a little palpitation, oppression or pain at the heart. The symp- 
toms subside with rest and care but recur, each time worse, the urine 
becomes albuminous and scanty; the liver enlarges, dyspnea increases 
and portal obstruction becomes evident. The pulse weakens, the heart 
dilates, with insomnia, headache, hemoptysis and irritative cough. The 
course may be slow, but sometimes it is not recognized until near the end. 
Cardiac asthma, bradycardia and Stokes- Adams respiration may occur. 
Arrhythmia, tachycardia and asthma characterize varieties; the latter 
due to pulmonary edema, with throbbing arteries. Vertigo, syncope 
and other evidences of feeble heart attend. The mind may be sluggish 
or deranged. Angina pectoris may occur. Death may be sudden or 
follow gradual wearing out. 

Inspection may disclose evidences of senility; palpation edema and 
an enlarged liver, stiff and tortuous arteries; percussion alterations in 
the size and shape of the heart; auscultation hypertrophy, weakness and 
valve murmurs, etc. 

The diagnosis considers the causal maladies and is considered under 
their heads. The same may be said of the prognosis. Pulse tension is 
important; rapid development of heart weakness is bad; intermittence, 
palpitation, gallop-rhythm and angina are unfavorable. Edema is peril- 
ous. Death may be due to intercurrents. 

Treatment: — The conservation of cardiac energy has been so fully 
treated under the head of valvular disease that repetition is useless. To 
the methods there described we have simply to add the hygienic routine 
indicated by the case, and the treatment of the special maladies under- 
lying the heart weakness, and accompanying the cardiac disease. Vascu- 
lar tension may require veratrine, gelseminine or aconitine, sclerosis may 
be delayed and possibly pushed back by the persistent use of arsenic 
iodide, the absorbable part of deposits may be taken up under the stimulus 
of mercury iodides, etc., angina pectoris is combated by arsenic iodide 
and glonoin, and the debility of the heart relieved by the mildest tonics 



HYPERTROPHY OF THE HEART 411 

the case will admit, saving the stronger till the period when nothing else 
will avail. Climate and the resources of regime are to be utilized to the 
full extent. But the problem of prolonging the life is one to be studied 
anew with every case, and there is no simple and easy way to manage 
that can be laid down for all, or even for a large number cf patients. 

HYPERTROPHY OF THE HEART 

The muscular fibers of the heart increase in size and possibly in num- 
ber, causing an increased thickness of the walls of the portion involved. 
The interstitial tissue is necessarily increased also, but much mere slowly 
than the muscular fiber. On section, the affected muscle is firmer than 
usual, and is deep red. If the supply of blood is insufficient, the hyper- 
trophy is partial and interrupted by areas cf fatty or fibroid degeneration. 
The heart is increased in weight, from the normal eight and a half ounces 
for a female, ten ounces to a male, bat more than double these weights is 
not uncommon. The largest heart weighed by the writer was twenty-six 
ounces, but much larger ones than this have been recorded. Concentric 
hypertrophy is quite rare, the cavity almost always being larger than 
normal. 

Etiology: — Hypertrophy of the heart is usually secondary to valvular 
disease, adherent pericardium, chronic myocarditis or arterial sclerosis. 
It also occurs as a consequence of interstitial nephritis, where the vascular 
tension is raised; in fact, continuous abnormal vascular tension from a 
cause will give rise to hypertrophy. It is sometimes due to congenital 
narrowness of the aorta or of the entire aortic system. In such cases, 
as in valvular disease, the hypertrophy is due to an effort of nature to 
overcome the obstacle in the circulation. The hypertrophy usual in the 
excessive beer-drinkers of Germany is attributed to the increased nutritive 
supply, probably with the stimulation of the heart by the alcohol. Sol- 
diers, mountaineers, those who carry heavy burdens, and the Japanese 
jinricky men, develop hypertrophy of the heart by excessive muscular 
exertion. It occurs also as a feature of exophthalmic goiter, and as 
sequel to emphysema and cirrhosis of the lung, pleural adhesions, and 
consequent deformity of the chest. 

Symptoms: — The symptoms are due to the effort of the heart to over- 
come an obstacle and sustain the circulation. Inspection may show the 
apex beat displaced downward, outward in hypertrophy of the left ven- 
tricle, inward if the right ventricle is affected. Palpation shows a full, 
powerful, slow pulse, with high tension, due to the forcible impulse; also 
the heaving impulse by which the entire chest may be shaken. Percus- 



4 i2 HYPERTROPHY OF THE HEART 

sion shows an increase of the area of cardiac dullness, over the portion 
or portions of the heart affected by the hypertrophy. As the heart grows 
heavier, it also sinks downward when the patient is in the erect posture. 
Auscultation detects a loud booming first sound, somewhat prolonged, 
high tension with the second sound at the base, or of the pulmonic second 
sound when the right ventricle is affected. 

Diagnosis: — The principal points are a full, tense pulse, slow or normal 
in rate; a powerful broad apex beat, displaced outward and perhaps 
downward; increased dullness to the left and upward, or universally; 
a booming, low-pitched first sound and accentuated aortic second sound. 
When the right ventricle is hypertrophied we have epigastric pulsation, 
dullness extending to the right and downward, and intense pulmonic 
second tone. The causal disease contributes its evidence. Displace- 
ment of the heart must be excluded. This may be due to curvature of 
the spine. Neurotic youths with thin chest-walls and broad intercostal 
spaces may show a rapid, forcible heart-action, resembling a hypertrophied 
organ, but without enlargement. 

Prognosis:— This depends upon the original cause of the difficulty. 
If this be progressive the morbid process will continue until the limit of 
possible hypertrophy has been reached, when dilatation and degenera- 
tion will follow. Occurring in the young, from over-exertion, the progno- 
sis is more hopeful. 

Treatment: — The treatment is to be directed to the cause of the malady. 
Since hypertrophy is a conservative process it is not to be interfered with 
unless, as often occurs, it should exceed the requirements of the situation. 
We therefore look to the treatment of the original disease and to regula- 
tion of the individual's hygiene, forbidding excessive exercise of every 
description as well as excitement, and the use of coffee, alcohol in every 
form absolutely, and hot drinks and soups excepting in moderation. When 
it is necessary to curb excessive hypertrophy we rely upon vera trine, in 
full doses, which also relaxes vascular tension and by stimulating all the 
eliminant organs carries out of the body the toxins that would otherwise 
irritate the heart and stimulate it to unnecessary exertion. Moderation 
in the use of strong foods is also to be enjoined. Symptoms of threatened 
pulmonary or cerebral apoplexy may demand venesection; or if less ur- 
gent, the quickest acting hydragogue cathartics, such as croton oil or 
elaterium. Patients with hypertrophy are liable to be affected by pul- 
monary apoplexy on making a quick trip from the sea-level to elevations 
of five thousand feet or more. When the true hypertrophy is merging 
into false, and direct vascular depressants are not well borne, solanine 
will admirably replace veratrine. 



DILATATION OF THE HEART 413 

DILATATION OF TNE HEART 

Primary dilatation occasionally occurs when, after a prolonged period 
of sedentary life, a man puts upon this organ the unwonted strain of pro- 
longed exertion, such as marching, climbing mountains, or engaging in 
athletic pursuits. With this exception dilatation is secondary to peri- 
carditis, myocarditis or valvular disease. It is, in fact, but one step in 
the process and may for a brief period precede the development of hyper- 
trophy, to which it succeeds in due course of time. The cavities affected 
are enlarged, the walls becoming stretched; the muscles flabby, the walls 
in time degenerated; the muscular tissue is pale, cloudy, sometimes stained 
with brown pigment. Dilatation may affect one chamber of the heart 
or all of them. Up to a certain point the valves opening into the dilated 
chamber will be elongated, but if the dilatation becomes extreme, the leaf- 
lets will not meet and relative insufficiency is established. 

Etiology: — Dilatation is due to pressure exerted by the blood dis- 
tending the affected chamber, with which its walls are unable to cope. 
The walls may be weakened by the general and local influence of acute 
infection. Relaxation is said to be occasioned by excessive emotion as 
well as excessive exercise; but in the vast majority of cases, where there 
has been an undue strain placed upon the wall of a cavity, hypertrophy 
has reached the physiologic limit and the strain still continuing, the wall 
dilates before the continuous pressure. In high altitudes a previously 
healthy heart may give way to the strain of unaccustomed exertion. Ex- 
cesses in tobacco, alcohol, sexual and social indulgences, also reduce the 
resisting power of the heart- wall. The danger from over-exertion is avoided 
by a careful, systematic and thorough training of the heart and the other 
muscles so as to render them capable of enduring severe exertion before 
they are called upon. It is the untrained or over-trained athlete, or the 
strong man whose muscles have fallen away during prolonged periods 
of idleness, and who forgets this fact, who suffer from over-exertion. Their 
mishap is a powerful argument in favor of athletic training, when in- 
telligently carried out and suited to each individual, who will thus be 
rendered physically capable of meeting emergencies presenting them- 
selves without doing himself an injury. 

Symptoms: — These may develop gradually or quite suddenly. The 
walls of the heart are weakened by over-distention and become incapable 
of keeping up the circulation; the heart becomes soft, feeble, rapid and 
irregular; the area of cardiac dullness enlarges; the impulse and the sounds 
weaken; dyspnea on exertion, with a sense of debility, are the first symp- 
toms noted by the patient, who loses color also, and may display the bluish 



4 i4 DILATATION OF THE HEART 

tint of cyanosis. The urine becomes scanty, the liver swells and becomes 
painful; the abdominal vessels become congested, appetite and digestion 
weaken, flatulence and constipation are present, hemorrhoids develop, 
the sexual power subsides, and women complain of menstrual derange- 
ments and leucorrhea. The ankles become puffy at night, this edema 
gradually becoming more pronounced. A cough becomes common, 
with hemoptysis. Conversation wearies the patient and hypostatic con- 
gestion occurs in the dependent portion of the lungs. The apex beat is 
almost imperceptible; the heart sounds almost inaudible, and relative 
mitral or tricuspid insufficiency contributes a murmur and increases the 
difficulty of the circulation. The symptoms steadily worsen, the dropsy 
ascends the limbs and appears in the serous cavities; the sensorium is dulled, 
and the patient dies of gradual exhaustion or of pulmonary edema. The 
heart may stop suddenly on quick exertion or some emotional disturbance. 

The course may be prolonged for years. If degeneration does not 
exist, acute dilatation from over-strain will subside if due precaution be 
observed; but if repeated, the lesion will become permanent. It is, of 
course, much more serious in persons who have passed the climax of life 
and entered upon the period of dicline. 

Diagnosis: — The cardiac impulse is weak or absent; the area of 
cardiac dullness is enlarged, generally or partially; the heart-sounds are 
feeble, and may be obscured by valvular murmurs. The first sound is 
short like the second; the interval is also shortened; at the base, the aortic 
second sound is weak, the pulmonic accentuated. The diagnosis is not 
difficult, the symptoms being characteristic in acute cases. Supervening 
gradually, we have the rapid, feeble, irregular pulse, weak, slapping or 
imperceptible impulse, increased dullness, and feeble sounds with accom- 
panying murmurs. Care must be taken not to confuse slowly developing 
dilatation with pericardial effusion. Hypertrophy is distinguished by 
the strong pulse and heaving impulse. 

Prognosis: The gravity of the case depends largely on the presence 
of degeneration. Acute attacks from over-exertion soon subside under 
judicious management. Interstitial nephritis renders the prognosis 
gloomy. The greater the dilatation the more serious the case. The 
most serious form is dilatation of the left ventricle; but it is also more 
amenable to treatment. Irregularity of the pulse indicating degeneration 
is a bad omen. Dyspnea which is more serious than the apparent condition 
of the heart warrants is also a bad indication. Great restlessness and 
nervousness should also arouse the suspicion of the physicain. Babcock 
says that this condition followed by a day of remarkable freedom is apt 
to be followed speedily by death. 



RELATIVE MITRAL INSUFFICIENCY 415 

TreBtmenf: Acute dilatation demands that the heart be placed at 
rest by confining the patient to bed until the circulation is restored. The 
bowels should be swept out by a prompt cathartic — a mercurial followed 
by a saline. Digitalin should not be given until after the cathartic has 
operated; it should then be administered in small doses frequently re- 
peated to desirable effect. The diet should be light, easily digested and 
unstimulating. Subsequently the amount and kind of exercise should 
be carefully regulated, and the patient kept under the physician's direction 
for a long time. 

When dilatation is replacing hypertrophy, or when repeated strains 
threaten to render the condition permanent, the treatment is that which 
has already been described in the chapter on valve lesions. If the pa- 
tient is desirous of prolonging his life to the utmost possible limit, with 
all the pleasure and usefulness which can yet be secured to him, he must 
pass his life under the care of a physician, who will so regulate it as to 
secure this result. 

Sometimes the symptoms of over-distention become so distressing 
that immediate relief is required. The heart-beat is a simple flutter- 
ing, feeble and irregular, the face congested, veins swollen, dyspnea ex- 
treme, the lungs rattling with serum, sputa bloody and frothy, the ex- 
tremities cold and blue; the heart is enormously dilated. The condi- 
tion may be so grave that there is no time for anything excepting a free 
venesection; the amount of blood taken to be regulated by the results. 
Subsequently we strengthen the heart with digitalin, strychnine and 
cocaine, while we reduce the bulk of the blood by saline cathartics and 
enemas, and the rigid enforcement of the dry diet. In these extreme 
cases, Babcock does not approve of the Nauheim baths; he also finds 
it difficult to credit the enthusiastic reports of benefit from the resistance 
exercises, although both these measures have a place in suitable cases. 

RELATIVE MITRAL INSUFFICIENCY 

This is a result of extreme dilatation of the left ventricle. It may 
be acute and transient or chronic and permanent. Predisposing 
are the diseases of the myocardium and aortic valves. Exciting causes 
embrace all influences causing abnormal strain in the left ventricle. Enor- 
mous physical exertion may give rise to dilatation enough to open the 
valve. Anemic girls occasionally present symptoms of this lesion; a 
systolic mitral murmur, enlarged heart, shortness of breath on exertion, 
etc. The symptoms have been described in the chapter on mitral leak- 
age. In the anemic form we may have a little edema of the ankles, but 



416 FATTY HEART 

the engorgement of the viscera is slight. Dyspnea is the principal symp- 
tom, with debility, loss of appetite, indigestion, constipation, and in- 
numerable evidences of autotoxemia. 

The diagnostic question lies in distinguishing these anemic cases. 
They have no history of rheumatism or other infectious disease; the anemia 
is evident. The murmurs are not transmitted to the back, and a sys- 
tolic murmur is usually to be heard most distinctly in the pulmonic area. 
The secondary heart-changes are absent. 

The prognosis is bad in organic disease; following heart-strain or 
anemia the malady is curable. 

The treatment of organic cases is that which has already been so 
fully described. The acute form occurring from strain subsides when 
the patient is kept at rest, with suitable diet and hygiene, as described 
under the head of dilatation. The anemic form subsides under the 
treatment of the blood condition. These patients can rarely bear cold 
bathing, but great benefit follows vigorous rubbing of the body with 
coarse towels dipped into hot salt water. As the strength increases, 
these same towels may be thus used after they have been dipped in the 
brine and then dried. In well-marked cases this method with the Nau- 
heim baths should precede sea-bathing. It is of the utmost importance 
that the digestion should be regulated and autotoxemia avoided. Neuro- 
Lecithin greatly enhances the other treatment employed to relieve the 
anemia. 

FATTY HEART 

This term is employed to designate the deposit of fat about the heart 
of the corpulent individual, to such an extent as to interfere with the 
functions of this organ. The fat lies beneath the epicardium and between 
the muscular fibers, which, however, are not necessarily degenerated, 
although they become atrophied with pressure. 

The heart may be loaded with an enormous amount of fat and yet 
perform its function satisfactorily. Romberg attributes the difficulty 
to the simple proposition that a heart large enough and strong enough 
for the needs of a man weighing 140 pounds becomes relatively insuf- 
ficient when his weight has doubled. Anemia may be present in such 
persons and a general lack of muscular tone. Symptoms of heart weak- 
ness appear after unusual exertion or weakening disease like influenza. 

The causes are those of obesity. It is in some degree hereditary 
but tends to occur after mid-life, as the active habits of youth are grad- 
ually laid aside for the quieter occupations of advancing years. Many 



FATTY HEART 417 

women fatten after the change of life. The use of large quantities of 
food and the excessive use of liquors favor the development of fat. Beer 
also acts probably by the relaxation of tone. Alcohol in any form, how- 
ever, is said to specially favor fatty overgrowth of the heart. However, 
the disease does not consist in corpulence, or in fatty overgrowth, but 
in the evident insufficiency of such a heart to earn* on its function satis- 
factorily. All luxurious habits that relax muscular tone aid in the devel- 
opment of this insufficiency. It may also show itself for the first time 
when such individuals attempt the reduction of weight not wisely but 
too vigorously, by too rigid abstemiousness, and such vigorous exercise 
as results in overstrain. 

Short breath is the first symptom, first noticed on ascending stairs, 
but produced by continuously slighter exertions, such as stooping. Ver- 
tigo comes next, when the patient rises to his feet after lying down, espe- 
cially if he then urinates. The pulse becomes rapid as the heart weakens. 
It is small also and weak unless cirrhotic nephritis or atheroma cause 
tension. The rhythm is also irregular. The appetite fails, discomfort 
and dyspnea coming on as soon as the patient has eaten a little. Thirst 
is great. He is flatulent, constipated, the urine scanty and red; he is 
sleepy after meals but wakeful at night; dull headache is common. Judi- 
cious measures taken to get rid of the superfluous fat improve the patient's 
condition greatly but the utmost care must be taken in making this at- 
tempt, if the heart muscle is degenerated. Evidences of failing circu- 
lation must be watched for. Pulmonary edema, asthmatic attacks and 
anginous paroxysms may occur. The liver swells and becomes tender. 
Albuminuria appears and edema becomes manifest in the ankles. The 
patient is confined to his chair as the dyspnea becomes extreme. Sleep 
is broken and unrefreshing, and the patient dies of exhaustion, unless 
sooner relieved by intercurrent affections. 

It is somewhat difficult to examine such patients on account of the 
obesity. The pulse affords reliable data as to the adequacy of the heart. 
A fairly strong, full, regular pulse indicates a correspondingly healthy 
condition of the heart. Any enlargement of the liver found may be fatty. 
It is impossible to tell by percussion whether increased dullness is due 
to enlargement of the heart or to mediastinal fat. The heart is apt to 
be crowded upward by the fat interfering with the descent of the dia- 
phragm. Auscultation also enables us to form a fair estimate of the 
strength of the heart. The diagnosis of cardiac insufficiency is not diffi- 
cult, being a matter rather of judgment than the detection of pathogno- 
monic signs. The prognosis depends upon the conditions, the age, the 
causes, the history as of strain, the habits and tractability of the patient, 



4 i8 CARDIAC ASTHMA 

but especially upon the presence or absence of degeneration of the heart 
muscle. Heart failure, angina, asthma and sclerosis are bad. 

Treatment: — The reader is referred to the chapter upon obesity. The 
patient must be warned against over-anxiety to reduce the weight quickly. 
The object is not so much a reduction of weight as it is of the establish- 
ment of a correct balance between the power of the heart and the work 
which it has to do. Hence we meet the difficulty by increasing the power 
or by lessening the work, or by both. Young patients will bear much 
more radical measures than older ones. The regulation of the diet and 
of the exercise forms a different problem for every case; the digestion 
must in all cases be kept up and nutrition sedulously maintained. The 
combination of corpulence with anemia, or enormous eating and under- 
nutrition, is by no means uncommon. In older persons who have long 
been accustomed to a full diet radical reductions are perilous. If active 
exercise is inadmissible massage gives us excellent results and prepares 
the way for resistance exercise to follow. The Nauheim baths are good. 
Babcock insists that in all cases of corpulence high tension exists in the 
abdominal vessels, requiring the persistent use of cathartics. 

CARDIAC ASTHMA 

Dypsnea is one of the first and most persistent symptoms of cardiac 
insufficiency. It is not, however, solely due to the mechanical derange- 
ment. Pain and nervousness may interfere with respiration; but apart 
from these the dyspnea is always induced by exertion. As the heart 
grows weaker the dyspnea increases and is induced by continually slighter 
causes until it becomes constant. In addition, however, we have intense 
paroxysms which have passed under the name of asthma, but are now 
termed cardiac asthma. Typical attacks occur at night, on lying down, 
or during sleep. The resemblance to true asthma may be very close. 
Moist rales may be heard over the chest, and frothy or bloody mucus 
may be expectorated. The distress is agonizing. The face becomes 
blue and is covered with perspiration; the pulse is rapid, weak and irregu- 
lar; the difficulty of inspiration is enormous. If the heart is examined 
during a paroxysm it is found to be dilated, the sounds weak and masked 
by moist rales. The attack may last for a few moments or for hours, 
and subside leaving the patient exhausted. These attacks are ascribed 
to a temporary weakness of the left ventricle and undue strength of the 
right, both contributing to cause excessive congestion of the lungs. The 
dyspnea is increased by pulmonary edema. If the patient has a weak 
left ventricle temporary excitement may induce an attack. Sexual ex- 



CHEYNE-STOKES RESPIRATION 419 

citement seems especially liable to do this. The increased blood pres- 
sure caused by lying down may explain the occurrence of a paroxysm 
during sleep; or possibly it is due to inadequacy of respiration when not 
assisted by voluntary effort. 

The treatment of cardiac as of essential asthma by narcotics must be 
condemned. Glonoin gives the quickest relief, and may be given gr. 
1-250 every five minutes. Prolong the action by administering hyos- 
cyamine, gr. 1-25 1 repeated every ten or fifteen minutes until the face 
flushes. Sustain the vital forces and the heart, and restore control over 
the respiratory nerves by strychnine arsenate, gr. 1-134 every half hour 
until pulse tone is restored; and you have the most effective treatment 
of the paroxysm, one directly indicated by the pathologic conditions. 
The treatment of the intervals is that called for by the underlying 
condition of the heart, and of the system at large. Autotoxemia is espe- 
cially to be guarded against, since the toxin in the blood is certain to act 
most injuriously upon the points of lowest resistance, the diseased heart 
and the hypersensitive pulmonary nerve ends. 

CHEYNE-STOKES RESPIRATION 

This occurs in paroxysms at regular intervals, alternating with nor- 
mal respiration. It begins with a suspension of breathing; then respira- 
tions begin, slow and shallow, each succeeding one coming quicker and 
deeper, until the rate is singularly rapid and forcible, the dyspnea being 
great. In a few moments this begins to subside and the respirations 
die away into apnea, the chest being motionless. The same thing is 
repeated over and over. The time occupied by a cycle is uniform in the 
same case, but not in any two cases; it is usually less than one minute. 
Consciousness is unaffected as a rule. The pupils are contracted during 
apnea, dilated during dyspnea. Rhythmic change has been observed. 
The pulse is sometimes unaffected, at others disturbed. The tension is 
usually increased. 

This phenomenon has been witnessed in a number of cerebral dis- 
eases, shock, uremia, alcoholism, opium poisoning and insanity; with 
lesions of the heart and great vessels, and in chronic nephritis. It is 
most frequent in diseases of the aorta and its valves. It has also been 
noticed in diphtheria, typhoid fever, pneumonia and other infectious 
maladies. 

Prognosis: — It is a bad indication, usually heralding the approach 
of death, although sometimes this has been postponed for months after 
the development of the symptom. The best prognosis is naturally 



420 STOKES-ADAMS DISEASE. 

when the phenomenon appears in the course of a disease not necessarily 
fatal, such as influenza. Babcock considers it less grave when occurring 
during sleep. 

Treatment: — The management is that of the underlying disease. The 
symptom may be relieved by hypodermics of morphine, with or without 
atropine; but the value of this remedy has been disputed. Looking 
upon irregular motor manifestations as indicating a weakened control 
by the nerve centers, strychnine would be the physiologic remedy; and 
as it is usually indicated for the underlying disease and the general con- 
dition of the patient, it would seem at any rate to be worthy of a trial. 

BRADYCARDIA 

This term designates an adult pulse of less than sixty to the minute. 
The pulse normally is sometimes less than sixty. Napoleon's was forty. 
Sometimes this is hereditary; occasionally this has been observed during 
hunger, and it is quite frequent in puerperal women. Allbutt has noted 
it in adults and children following sexual excess. Riegel has noted 
bradycardia during convalescence from pneumonia, diphtheria* typhoid 
fever, erysipelas and acute rheumatism. Sanson includes influenza. 
It has been noted also in chronic dyspepsia, gastric ulcer and cancer, 
and jundice; as well as esophigeal cancer and typhlitis. It is met in 
emphysema and some diseases of the heart and great blood-vessels, espe- 
cially the scleroses; in acute nephritis, uremia and hematuria, in poison- 
ing from lead, tobacco, coffee, alcohol and digitalis; in diabetes, chlorosis 
and anemia; in apoplexy, epilepsy, brain tumors, disease of the medulla 
and cervical cord, paresis, melancholy and mania; in some skin diseases, 
genital affections, sunstroke, and in exhaustion from any cause. 

Regnard says it may be caused by any chronic lesion causing . irrita- 
tion of any portion of the moderator apparatus of the heart. 

In diseases of the circulatory apparatus bradycardia is of serious 
importance, usually indicating sclerotic degeneration. Death may occur 
in syncope or after very slight strain. It is therefore, an indication for 
careful examination of the heart. 

STOKES-ADAMS DISEASE 

This term signifies a paroxysmal intensification of preexisting brady- 
cardia, with vertigo, syncope and epileptoid attacks. 

It is most usual in elderly men. The pathology is obscure. Huchard 
attributes it to arteriosclerosis of the coronary arteries. Fatal cases ; 



STOKES-ADAMS DISEASE 421 

however, have revealed no lesions to which the malady could be attributed. 
Other causes to which it has been attributed are : anemia, syphilis, dietary 
errors, indigestion and obstipation. Tripier looked upon the disease as 
a form of epilepsy. 

Symptoms: — We have first bradycardia and other disorders of the 
circulation, vertigo and syncope, epileptiform convulsions and disorders 
of respiration, the last being uncommon. The pulse is slow and regular 
during the attack, sinking to 20 or less. Vascular tension is great; the 
pulse does not respond to stimulants or to exercise. In two cases digitalis 
raised the pulse to fifty. Auscultation may detect a faint murmur during 
the pause. Feeble pulsations are noted in the right internal jugular vein, 
just above the clavicle, synchronous with the heart. Vertigo is present 
in all cases and is not relieved by lying down. Syncope lasts but a few 
seconds and is followed with a flush like that produced by glonoin. The 
pulse is absent during syncope. Epileptiform convulsions may accom- 
pany it, limited to the mouth, or one or more extremities. The paroxysms 
may occur at varying intervals, sometimes several in a day. Babcock 
describes the case of a young man who enjoyed immunity while on a 
vegetarian diet; his attacks were traceable to the intestinal canal, the 
urinary solids being reduced on the days on which attacks occurred, and 
increasing when they were absent. This pointed to autotoxemia as a 
cause of the attacks. Jaquet's observations were in harmony with this, 
the seizures disappearing when indigestion and constipation were 
remedied. 

The diagnosis may be difficult when we have a vertigo and an in- 
creasing bradycardia. The addition of syncope and the convulsions 
completes the picture. There are periods of unconsciousness, the pa- 
tient possibly falling, and we may find rigid arteries or evidences of disease 
of the heart. Occurring in a person much under forty, it is difficult to 
separate from epilepsy, but the slow pulse is not significant of the latter. 

The prognosis is grave and uncertain. The underlying disease may 
determine the possibility of recovery. 

Tredtment: — Hitherto the treatment has not been satisfactory; in one 
anemic case inhalations of oxygen, with a suitable diet, were followed 
by recovery; in other cases oxygen failed. One of Stokes' cases found he 
could prevent or mitigate an attack by going on his hands and knees 
with his head hanging down. The most significant observations yet 
made are the improvement following the use of digitalis and the preven- 
tion of autotoxemia by proper attention to the diet and to the bowels. 

Apocynin seems to be indicated here, as it acts smartly on the bowels 
and as a tonic to the heart. 



422 ANGINA PECTORIS. 

ANGINA PECTORIS 

This term designates paroxysmal attacks of pain in the heart, of a 
neuralgic type, with a sense of constriction and impending death. This 
malady has been found in connection with every known disease of the 
heart and of the great vessels; but with no one of these diseases is it al- 
ways present, nor is any one of them always present with angina. There 
are various grades of angina pectoris, varying from extreme mildness 
to extreme severity and corresponding danger. Perhaps the most fre- 
quent attendant of the severer form is sclerosis of the coronary arteries, 
especially when it interferes with the supply of blood to the heart; in 
fact, interference with the supply of blood for the nutrition of the heart 
has been held to constitute the essential pathologic condition causative 
of angina. 

In ordinary circumstances the supply of blood may be sufficient, but 
when an unusual supply is required, or when emotion interferes with 
the ordinary supply, a paroxysm is induced. The pain is claimed to be 
curative in that, by placing the patient in a condition of enforced rest, 
the need for an extra supply subsides. This argument must appear to 
anyone who has felt or witnessed these agonizing attacks to be paltry 
and far-fetched. Huchard claimed that abnormal and excessive cardiac 
irritation always aroused a paroxysm. 

Angina pectoris is a disease of men over sixty years of age, although 
it occurs exceptionally in much younger patients. Men are much more 
frequently affected, especially those who are particularly well fed. One 
of the writer's most marked cases occurred in a woman thirty-three years 
of age, in the last stages of pulmonary tuberculosis. Angina is some- 
times hereditary. Gout, interstitial nephritis and other causes of atheroma 
are predisposing causes of angina. To these we may add syphilis, alco- 
hol and tobacco. 

The exciting causes of the severer form are anything that will suddenly 
raise vascular tension, such as sudden muscular effort, exposure to cold 
wind, exercise immediately after full meals, strong emotional excitement, 
a cold bath, sexual intercourse, flatulence, and in some individuals tobacco. 
Tea and coffee have been known to cause attacks. The milder cases, 
known as false angina, are, according to Huchard, never due to muscular 
exertion. They may occur during sleep, and may then be attributed to 
flatulence, chilling of the room, or getting into awkward positions. 

Symptoms: — The patient may never have had any symptom referable 
to the heart; he is suddenly seized with an agonizing pain in the region 
of the heart, with a sense of oppression or weight, or of impending death. 



ANGINA PECTORIS 423 

The pain is agonizing; patients almost always describe it as if the heart 
were being crushed in the grasp of an iron hand. The duration of the 
paroxysm is short, though it is difficult to convince the patient of this. 
Nocturnal attacks are longer than those occurring by day, and more 
severe. Death has occurred with a first seizure. Usually the parox- 
ysms tend to recur with greater frequency and severity; sometimes they 
become almost continuous. The pain runs along the intercostohumoral 
nerve to the inside of the left arm, down as far as the elbow in some cases. 
The patient may locate the pain under the upper part of the sternum. 
In severe attacks the face is pale gray or bluish, covered with cold sweat, 
the extremities and the tip of the nose are cold, the pulse small, tense and 
wiry. Speech is impossible and respiration is repressed. The pain may 
extend in any direction widely from the heart. The patient is usually 
motionless during the height of the paroxysm and sitting or standing up. 
The seizure usually subsides as suddenly as it occurs, leaving a sense 
of numbness, soreness or motor paresis of the arm. 

The course is exceedingly variable, and paroxysms may recur during 
many years. Gardner has described a form in which the other symp- 
toms are present, but no pain. 

Diagnosis: — Two features are essential to the diagnosis of angina 
pectoris — the crushing sensation and that of impending death. We 
may have intercostal neuralgias extending into the left shoulder and 
arm, which are not anginas, and may never develop into angina, although 
they occasionally do. Usually the tender points of Valleix distinguish 
these. They are more frequent in women and in anemic, neurotic persons. 
They occur in much younger persons than true angina. They are also 
unattended with sclerotic or other disease of the heart or great vessels. 
In many cases, we have such attacks which are not true angina, in women 
with large hearts who have long been autotoxemic. If the patient is able 
to walk, sit, lie down or moan during the paroxysm, it is probably not a 
true angina. Nevertheless there are cases on the borderline between 
the two groups, and it is not impossible that the mildest case may in time 
develop into the graver malady. 

Prognosis: — Angina pectoris is a grave disease, the possibility of 
sudden death in a paroxysm always being present. It is impossible to 
predict the probable duration of life. Attacks recurring from slighter 
cause, with greater severity and frequency, are ominous. Nevertheless, 
the malady is by no means altogether hopeless. 

Treatment: — Recognizing the paroxysm as a condition of intense 
vasomotor spasm, the remedy is glonoin. Patients liable to this disease 
should carry a supply of these granules, loose in the vest pocket, so that 



4 2 4 ANGINA PECTORIS 

they can be taken instantly. The granules do not deteriorate. The 
remedy is absorbed from the mouth and its effects are then more rapidly 
exerted than when taken hypodermically. Gr. 1-250 can be used at first, 
and repeated every five minutes until the spasm relaxes. If this prove 
insufficient the dose should be increased until the desired effect is obtained. 
Ordinarily the spasm does not last longer than the brief period during 
which the action of glonoin endures; but if the paroxysm be prolonged 
hyoscyamine should be added in similar doses. It is better to have the 
two combined in a single granule. When thus administered the effect 
of hyoscyamine is manifested more promptly than when given alone. 
The clinician who looks upon spasm as invariably indicating a weakening 
or loss of control by the nervous system over the part involved, will add 
to the above combination strychnine arsenate in similar doses. These 
minute doses of strychnine aid in the restoration of nervous control, while 
the arsenic is believed to favorably influence the nutrition of the heart. 

The treatment of the intervals, however, is another matter, and must 
depend in great measure upon the cardiovascular disease underlying 
the malady. The writer has for many years been accustomed to admin- 
ister that powerful absorbent , and alterative arsenic iodide, in doses of 
gr. 1-67 four times a day, to all cases of arteriosclerosis, continuing the 
remedy as a rule for a year or more. In the meantime the utmost pains 
are taken to enforce an exact hygienic regime, to prevent autotoxemia 
and sustain the nutrition of these patients at the highest point, without 
overdoing the matter. During more than fifteen years every patient 
thus treated has manifested a slow but steady improvement, the parox- 
ysms becoming less frequent and less severe, the circulatory conditions 
improving, the patient picking up hope and gradually acquiring a firm 
conviction of his own well-being. I cannot persuade myself that the 
treatment is useless, and that I have been guilty of self-deception in believ- 
ing that it has materially benefited my patients. 

Since the paroxysm is a vasomotor spasm it may be of importance 
for the reader to recollect that in the absence of glonoin and hyoscyamine, 
there are other remedies that relax such spasm. Inhalations of amyl 
nitrite do this even more quickly than glonoin, but the pearls of amyl are 
not so handy as the granules of glonoin. Inhalations of ether also give 
relief, but Anstie gave his warning that a chloroform inhalation was apt 
to be followed by instant death. Hoffman's anodyne, sweet spirits of 
niter, alcohol, ammonia, camphor, capsicum, pepper, any volatile oil, 
in fact, a dose of any remedy that is "hot enough to bring tears to the 
eyes" will relax such spasms. Obviously the remedy should not be 
diluted more than is absolutely necessary. Hot mustard foot- and whole 



SYPHILIS OF THE MYOCARDIUM. 425 

baths, and sinapisms over the pneumogastric nerve in the neck, have 
some effect in this way and could be utilized in the absence of more 
effective remedies. 

During the intervals the patient should be carefully trained in the 
means of avoiding the exciting causes of such attacks. Cold winds are 
to be avoided, as well as sudden exertions and emotions; the hands, feet 
and head must be kept warm; in fact, the patient necessarily becomes 
a valetudinarian, eternal vigilance being essential to the continuance of 
his life, at least until the treatment above mentioned has materially modi- 
fied the causal affection. If heart-tonics are required it is better to employ 
those which, like strophanthin, have the smallest vasoconstrictor effect. 

SYPHILIS OF THE MYOCARDIUM 

There is a form of fatty degeneration caused by syphilis, indistinguish- 
able from that due to other causes. The interstitial myocarditis accom- 
panying syphilitic arteriosclerosis may be specific or not. Gummata 
are rare. 

If any symptoms are manifest they are indistinguishable from the 
same malady as caused by other affections. The heart-action is irregular. 
Semmola insisted on the presence of arrhythmia and rapidity of the pulse. 
There may be a sense of distress or even pain about the heart, or dyspnea. 

When evidences of cardiac derangement appear in persons with clear 
syphilitic history, the specific nature of the lesions may be inferred, though 
this is not positive. If the patient is comparatively young, under 50, 
with no history of rheumatism or other infection capable of originating 
the heart malady, the inference is strengthened and the beneficial effects 
of antisyphilitic treatment go far to confirm the diagnosis. 

The prognosis is good enough to make it a matter of congratulation 
to any one showing a heart-lesion, if a syphilitic infection can be assigned 
as its cause. But if the disease is not suspected and treated before struc- 
tural damage has been done, it must be noted that mercury does not 
create new tissues to replace those destroyed. 

As it is essential to check the progress of the malady as quickly as 
possible, to stop the destruction of tissue, the speediest of remedies are 
indicated. Hence we urge the use of mercury biniodide gr. 3-67, iodo- 
form and phytolaccin each gr. 1-2, and arsenic iodide gr. 1-67, every four 
hours until irritation of the eyelids indicates full desirable effect, then less 
frequently, to sustain the effect. From this combination much better 
effects can be secured than from potassium iodide or any mercurial salt, 
alone or together. The heart-symptoms may require also tonics for 



426 



ATROPHY OF THE HEART. 



temporary use, and the other treatment suitable to the case, with iron 
for resultant anemia, hydragogs for oppression or dropsy, etc. 

MYOCARDIAL TUMORS 

Tuberculosis of the myocardium may accompany that malady else- 
where, appearing in the form of miliary nodules or as an interstitial myo- 
carditis. Hydatid cysts and other parasites have been found, as rare 
pathologic curiosities. Cancer rarely occurs, lipoma and fibroma still 
more rarely. Even secondary carcinomatous growths are uncommon. 
There are no distinctive symptoms. 



ATROPHY OF THE HEART 

Atrophy of the left ventricle attends extreme forms of mitral stenosis, 
and aortic disease where the supply of blood to the coronary arteries is 
deficient. The heart atrophies as age comes on; it is sometimes con- 
genially small, and usually smallness of the genitalia is then also present. 
. The heart is brownish or yellowish, wrinkled, tough, the fibers shrunk' 
and stained by pigment. Fat is absent. 

The heart atrophies in marasmus, from phthisis, cancer, diabetes, 
chronic suppuration, etc. To the symptoms of the causal malady may 
be added those of weakness of the heart, a weak, rapid pulse of small 
volume, feeble impulse and sounds, without stasis but a decided tendency 
to syncope on rising. The reduced size of the heart may be demonstrated 
by percussion or by the x-ray. The prognosis is that of the cause. Fatal 
syncope may occur at any time, especially when the patient rises to urinate. 

This is one of the rare cases in which moderate doses of alcohol are 
useful, relaxing vascular tension and favoring a better flow of nutritive 
blood to the heart. Persons so affected should have wine by their bed- 
side and take a small dose a few minutes before rising to urinate. The 
heart-tonics are unsafe if given in full doses, but minute doses of cactus 
or sparteine seem to favor the nutrition of the heart. The diet should 
be small in bulk, rich in nutritious value, and with an excess of proteids 
unless otherwise contraindicated; while artificial digestives should be 
used freely. Carefully arranged exercises may assist in increasing the 
growth of a small heart, in the young. Elderly patients must be warned 
of the imminent danger ran by sexual indulgence, during which many 
of these cases end in death. 

The writer has recently heard of the death of a former patient at the 
age of 92, in whom he diagnosed cardiac atrophy twenty years ago. 



DEXTROCARDIA. 427 

CARDIAC THROMBI 

A few cases have been recorded in which pedunculated thrombi have 
been found in the heart, usually in the auricles, especially the left. Still 
more rarely disconnected balls of fibrin have been discovered, post mor- 
tem. These result from deposits of fibrin upon a nucleus, probably 
of coagulated blood. They are more common in women, and those who 
have disease obstructing the auriculoventricular valves. 

The symptoms are those of extreme obstruction of the affected valve, 
the dyspnea continuing during rest. Cough and cyanosis are prominent. 
The abdominal viscera are congested, urine scanty and albuminous, 
dropsy present. The pulse is strikingly small and feeble, this and the 
venous engorgement being out of proportion to the valvular lesion. In 
all his three cases von Ziemssen found gangrene of a circumscribed area 
on the foot, with edema and cadaveric coldness of the extremities. He 
attributed this to thrombosis in the scantily-filled arteries. The mur- 
mur characteristic of the valvular affection is apt to be lost. 

No diagnosis has yet been made during the life of the patient. Von 
Ziemssen requires for diagnosis the demonstration of a preexistent mitral 
stenosis, excessive evidences of obstruction, and the gangrene described. 

The prognosis is bad. 

As yet the surgeons have not removed any cardiac thrombi. 

DEXTROCARDIA 

When this occurs congenitally the other viscera are usually also trans- 
posed. No symptoms result from such transposition if alone. 

When the heart is pushed into the right chest the vessels attached 
to the base are twisted or stretched. Obstruction is likely. The dis- 
placement is sometimes caused by pneumothorax or pleurisy, and if the 
heart contracts adhesions it may be retained in its new position. The 
lung fails to expand. Injury of the lung and tuberculosis may be the 
primary causes. 

The symptoms are those of the circulatory obstruction, cyanosis, 
dyspnea, weak rapid pulse, palpitation, scanty urine, and in time dropsies 
with venous engorgement. In extreme cases the spine becomes curved 
to meet the vacuum. The diagnosis is not difficult. The prognosis 
depends largely on the causal malady, and the degree of obstruction to 
the circulation. 

Just why the surgeons have not freed the heart from its encumbrances 
and restored it to its natural location is difficult to comprehend. 



428 CARDIAC NEUROSES. 

CONGENITAL IMPERFECTIONS 

Imperfection of the septum cordis is attributed to narrowing of one 
of the great arteries by which a stream of blood is diverted to the other 
side of the heart. The usually assigned cause is fatal endocarditis from 
infectious disease of the mother, or due' to a tendency to degeneracy. 

An open foramen ovale may cause no symptoms, and be compatible 
with long life, especially if there is little or no contraction of the aorta 
or pulmonary artery. But if the latter is narrowed cyanosis will be evi- 
dent. Such children are ill-developed, backward, sluggish, stunted, 
their profile is prognathous, the sternum projects, their fingers and toes 
club. Cyanosis is most evident in the lips and other parts naturally 
red. It is worse on exertion. The blood is of high specific gravity and 
contains an excess of red cells and hemoglobin, sometimes also of white 
cells. These patients are very susceptible to cold. Dyspnea attends 
venous stasis, or is disproportionately manifested. 

Physical examination may detect pulmonary valve or artery disease. 
The pulse is of greater volume when the septum allows an additional 
quantity to flow into the left heart. If the pulses of the lower extremities 
are larger proportionally than those of the upper, Botalli's duct remains 
open (Kolisko). Percussion indicates enlargement of the right ven- 
tricle. In some but not all cases there is a loud systolic murmur most 
distinct at the base, not limited to any valvular area. 

The diagnosis is evident from the history. The prognosis is bad as 
the pulmonary obstruction is decided. Few cases live to maturity. When 
compensation begins to fail it is not easily restored. The treatment is 
symptomatic. 

CARDIAC NEUROSES 

We find in some cases disordered heart-artion, pain and other abnor- 
mal sensations about the heart without perceptible organic disease. These 
may be due to some as yet undiscovered affection of the heart structure, 
to maladies of other parts, such as the nerve centers, or to conditions 
of the blood, like autotoxemia. 

Palpitation: — We find in this affection the heart beating more rapidly 
and forcibly than normal; the attacks occur suddenly, the heart thump- 
ing against the ribs, greatly alarming the patient. The pulse may be 
but slightly above normal or double its usual rate. It may be regular, 
irregular or intermittent. Intermittence may occasion a sinking feeling, 
a powerful throb following. The arteries in the neck or abdomen pulsate; 
the radial pulse varies in rate and force. The face may be flushed or 



CARDIAC NEUROSES 429 

pale, the extremities cold. Pain may accompany or follow the paroxysms, 
or an indescribable sense of distress about the heart. Some patients com- 
plain of feeling their arteries beat throughout the body. These cases are 
frequently associated with hysteria, with sexual and other forms of neu- 
rasthenia, and almost always there is present digestive disorder of some 
kind. 

Pseudoangina: — Pains in the region of the heart are very common 
in neurotics, who are usually apprehensive of heart disease. The weather 
citen appears to influence these pains, or they may follow exercise involv- 
ing the muscles of the chest. The anxiety usually present is probably 
psychic. Palpitation, cold extremities and other evidences of disturbed 
vasomotor equilibrium may also be present. There is no resemblance 
between these pains and true angina pectoris, except perhaps they both 
hurt. No organic disease of the heart is to be found. The intercostal 
nerves may be affected, or some other nerves, or the starting point of 
the difficulty may be in almost any part of the body, and passing along 
the reflex paths manifest itself by pain about the heart. Nevertheless, 
while no disease may be demonstrated in the latter organ, it is well known 
that reflex disturbances usually appear at the point of lowest resistance. 
Hence we need not be surprised if in the course of time organic disease 
may become demonstrable in this organ. 

The reflex angina is the most common form, and in the abdomen 
we find the majority of the sources of the irritation. Tobacco is a com- 
mon cause. The pain may be agonizing, and be attended by a sense 
of apprehension; the pain may radiate to the left arm, which may be 
cold and numb; sinking sensation and even a clutching at the heart may 
be felt. In cases of the vasomotor type the face is pale and anxious, 
extremities cold, skin clammy, the pulse weak, slow and irregular; but 
the patient does not as in true angina assume an erect, motionless atti- 
tude, but moves about and moans or cries. Catalepsy occasionally, 
however, occurs. The attacks "occur suddenly, often at night, and may 
be preceded by chilliness, restlessness, or general discomfort; regular 
periodicity may be noted. The pain may endure for several hours, 
leaving the patient exhausted. Many recurrences have been noted. 
In reflex cases the neuralgic type is pronounced. The vasomotor form 
may be excited by cold. A toxic form is very uncommon. Vertigo, 
pallor, syncope, precordial anxiety, a small tense pulse, cold extremities 
and perspiration characterize tobacco cases, with the other symptoms 
of nicotine poisoning. 

Etiology: — We have as a predisposing cause a mental and nervous 
equilibrium easily destroyed. In many cases there may be said to be 



43o 



CARDIAC NEUROSES 



a leakage of nerve force occasioning a shortage in its supply. An im- 
perfect organ, like a defective eye, may acquire the power of attracting 
to itself an abnormal supply of nerve force, and some other organ being 
unable to retain its share has to do without it. We call the latter the 
area of least resistance and here we have manifestations of disease. The 
prominence of emotional temperament renders women the most frequent 
victims of this affection, but it frequently occurs in men, in both sexes 
attacking individuals during early adult life. The change of life is another 
period in which attacks are common. Sometimes the malady dates 
from an emotional shock; at other times it occurs after a full meal, or 
from autotoxemia. Mental influences have, however, much to do with 
the occurrence, and patients who are expecting a paroxysm will generally 
have it. 

Diagnosis: — We find the history of a neurotic, often hereditary, no 
organic heart-disease discoverable; the age often much less than that 
at which sclerosis is manifested, and no history of rheumatism or infectious 
maladies determining endocarditis. The influence of the other causes 
mentioned may be demonstrated in special cases. The x-ray may be 
required to satisfy the patient that no organic disease exists. Head 
demonstrated the presence of certain tender areas corresponding to the 
distribution of the fourth and fifth intercostal nerves; these are: near 
the left nipple, on the fifth rib or the interspace above or below it, on the 
fourth costal cartilage or the interspace below it, at the sternal margin, 
and over the ensiform cartilage. Painful points are also to be found near 
the inferior angle of the scapula. These attend functional and organic 
disorders of the stomach. In diseases of the thoracic organs similar 
tender areas are found higher up. 

Prognosis: — This depends on the underlying condition. The cases 
are apt to be chronic, they are difficult of management, and the patients 
are exceedingly likely to change physicians whenever, as is usual, they 
feel neglected. 

Treatment: — The underlying condition requires its own treatment. 
The utmost pains should be taken in these cases to trace the malady 
to its source. It may be found in autotoxemia, in distant and usually 
unsuspected sources of reflex disturbance or rather of the leakage of 
nerve force, as in the case of an imperfect eye, which is called upon to 
do so much work that the defect is intensified. In a number of cases 
the cause will elude us unless we inquire into the sexual realm. Examina- 
tion may detect abnormalities in the sexual apparatus, and these how- 
ever slight and inconsequent they may appear should be remedied. It 
is astonishing what brilliant cures occasionally result from the removal 



TACHYCARDIA. 431 

of such sources of irritation. The sexual life should also be most care- 
fully investigated, for sometimes sexual excess, much more frequently 
sex hunger, underlies these manifestations. The paroxysm may be relieved 
most quickly by the combination advised in treating angina — glonoin, 
hyoscyamine and strychnine; the bowels should of course be emptied 
and fecal poisoning stopped. The physician should not rush off to dig- 
italis the moment the idea of " heart-disease" flashes across his mind. 
The causal indications treated, small doses of the milder heart tonics, 
such as cactus or cypripedin, frequently afford great relief by aiding 
in the restoration of central control; but if inhibition is evidently deficient, 
we may with advantage administer aconitine enough to discipline the 
unruly rebel; or gelseminine if sexual erethism is manifest. A few small 
doses of the valerianate of caffeine or of zinc usually restore self-control 
to the patient and allay apprehension. Ice or mustard over the pneu- 
mogastric nerve in the neck relieves pain and subdues spasm. There is 
no real need for either opiates or alcohol in these cases and with such pa- 
tients there is an enormous danger of the formation of a drug habit. 

TACHYCARDIA 

Sometimes tachycardia occurs without any evidence of cardiac disease. 
No anatomic changes characteristic of the malady have been detected. 
One observer attributes the affection to paresis of the vagus, another 
to irritation of the sympathetic, a third to both. The causation is obscure. 
Most cases occur in adults. It seems sometimes to be hereditary. Among 
exciting causes have been noted; a blow on the chest, strong emotion, 
and sudden strong physical exertion. Digestive difficulties have also 
preceded the attacks. Romberg says the disease may be reflex. 

To establish the existence of such a case the apparently healthy heart 
must beat at least 160 times a minute, and the attack must be sudden 
and abrupt in onset and in ending. The pulse has run up to 300 a minute. 
It is small and thready, generally regular in rhythm. The face may 
be pale or flushed; there may be a sense of oppression about the heart, 
with pain, numbness or tingling of the arm, and vertigo. Great alarm 
is occasioned by the attacks. In long attacks the circulation is not sus- 
tained, the heart becomes distended, the venous system engorged, with 
cyanosis and jugular pulsation. The lungs are congested. There may 
be slight edema and albuminuria. The heart sounds are feeble, the 
first sound at the apex almost inaudible. However, it is but rarely that 
the paroxysm endures long enough to occasion such symptoms. On 
subsiding the patient is left weak and apprehensive. The tachycardia 



43 2 



ARTERIOSCLEROSIS. 



persists even during sleep. The recurrences are not regularly periodic. 
The attacks vary in duration from a few moments to several weeks. 

Diagnosis: — The diagnostic question is as to whether the affection 
is essential, or accompanies some organic disease of the heart. The malady 
does not appear to endanger life, unless in the aged and feeble. 

Treatment: — Digitalis has been tried and proved wanting. Some 
patients are able to check a paroxysm by taking a full inspiration, followed 
by a forcible expiration aided by compressing the abdomen. The treat- 
ment during the intervals depends strictly on what the physician finds 
to treat. 

III. DISEASES OF THE ARTERIES 



ARTERIOSCLEROSIS 

The latest accepted theory in regard to this disease is that of Thoma. 
The middle arterial coat relaxes with consequent slowing of the blood- 
stream. Connective tissue hyperplasia occurs under the endothelium. 
The same process takes place when a volume of blood but partly fills 
the vessels. The process may occur in nodules or be diffuse. In the 
former light-colored patches project into the vessels; in the diffuse form 
the wall is stiff, and dilated with projecting zones and patches on the 
endothelium. As the patient ages the arteries become stiff, tortuous 
and dilated. Chalky plates project into the vessels, or the diseased patches 
break down into ulcers. The new connective tissues degenerates into 
hyaline masses with a fine granular detritus containing fat drops. These 
discharge into the blood-current. Lime deposited in others forms pro- 
jecting plates, and the artery may be transformed into a chalky tube. 
Degeneration of the middle coat occurs, and the weakened vessel dilates. 
The muscle fibers become atrophied and degenerated, the elastic elements 
disappearing. The outer coat is infiltrated with round cells. In the 
smaller arteries the lumen is so obstructed as to seriously interfere with 
the circulation. Large vessels become dilated. The disease is not mani- 
fested equally in all arteries, being most frequent in the ulnar and anterior 
tibial; least so in the brachial. Nodules are most frequent in vessels 
whose course is crooked, or which give off branches at a sharp angle. 
Parts subjected to the greatest strain are most affected by the disease. 
Similar lesions are found in the heart, kidneys and livers. 

Etiology: — That this disease occurs most frequently in advanced 
years, is because the strain upon the blood-vessels to which it is due has 
then be operative long enough to give rise to the disease. Men are more 



ARTERIOSCLEROSIS 433 

frequently affected because their occupations and habits render them 
more liable to the disease than women. Arteriosclerosis develops in 
men whose occupation necessitates unusually severe physical exertion, 
especially if such work is begun in early life. Syphilis is a very common 
cause of this disease; chronic lead-poisoning, alcoholism and gout are 
also established causative factors. The excessive use of tobacco is blamed 
by many. Romberg finds the disease common in neurasthenics. ' When 
vascular tension has been abnormally high throughout the body the disease 
is general. Corpulent persons of sedentary habits are first affected with 
sclerosis in the splenic, hepatic and superior mesenteric arteries, where 
blood-pressure is habitually high. In workmen the disease is attributed 
to the alternation of strain and relaxation. In brain-workers the disease 
is apt to occur in the cerebral vessels. Hypertrophy of the heart increas- 
ing the pressure in the coronary arteries, sclerosis is common in these 
vessels. This may explain also the frequency of angina pectoris with 
coronary sclerosis in modern business men (Babcock). Persons with 
mitral disease or chronic phthisis have sclerosis of the pulmonary artery. 
In diabetes the affection is general. 

Symptoms: — The disease is long latent. Sometimes the affection 
is manifested by renal inadequacy, cardiovascular disorder, or disturb- 
ance in the circulation of the brain, the extremities, the digestive organs 
or the heart. When interstitial nephritis lessens the supply of blood to 
the kidneys, sclerosis occurs in the renal arteries. It is easier to com- 
prehend why in most cases sclerosis is the primary causal affection. The 
quantity of urine is increased, its specific gravity is low, as the kidney 
contracts the excretion of urine becomes smaller. The general vascular 
tension rises, sclerosis appears in the heart and elsewhere, hypertrophy 
follows with incompetence in time. In other cases, dyspnea with weaken- 
ing heart precedes renal symptoms. 

In another form the symptoms depend principally upon the arterial 
disease. The vessels are stiff, tortuous and beaded; the pulse small and 
weak; the veins project; the urine is scanty and thin, with a very few casts 
and a trace of albumin; debility increases, appetite and digestion weaken, 
the ankles swell, the patient wastes, loses color and at last dies from gen- 
eral debility. Nutrition suffers, because the arteries neither receive nor 
transmit the full supply of blood, which collects usually in the veins. 

Interference with the blood-supply shows itself in the disturbed func- 
tion of the part most affected. If it be the cerebral arteries the mental 
faculties are impaired, the patient complains of headache and vertigo, 
especially on arising after lying down; and debility increases. These 
symptoms indicate partial cerebral anemia. Rarely this may occasion 



434 ARTERIOSCLEROSIS 

epilepsy, developing late in life. It is also the most common cause of 
apoplexy, occurring from the rupture of a minute aneurism at the site of 
a sclerotic ulcer. 

Occurring in the medullary arteries sclerosis is a cause of the Stokes- 
Adams disease. Affecting the arteries of the legs it gives rise to various 
abnormal sensations, disorders of motion, such as intermittent claudica- 
tion, cramps, etc.; to vasomotor disturbances; trophic disorders, and if 
a vessel is totally obliterated, to gangrene of the parts supplied by it. 
Many of these disturbances appear only when a demand is made for 
more blood than when the part is at rest. From this cause we have in- 
flammatory symptoms, senile gangrene, local necrosis and the symptoms 
of Raynaud's disease occaisonally developing. 

Interference with the circulation through the coronary arteries leads 
to angina pectoris, degeneration of the heart-muscle and general cardiac 
incompetence; while the diffuse form of the disease, by increasing vas- 
cular tension, induces hypertrophy of the left ventricle. It seems to be 
sclerosis of the abdominal arteries which especially causes general hyper- 
trophy of the heart. 

In still another form, especially appearing in working men, the disease 
is associated with chronic bronchitis and emphysema; the urine is light 
and slightly albumious; the right hypertrophied. 

The course of the disease is generally exceedingly slow. 

Physical Signs: — In one type the patients are corpulent, with flabby 
abdomen, in another thin, poorly nourished, with tortuous arteries plainly 
pulsating; the veins are prominent. The arteries are stiff and thick, 
not compressible, tortuous, beady, sometimes studded with little aneurisms. 
The arterial thrill is easily elicited; hypertrophy may increase the dull 
area of the heart. The second sound in the aortic area is even more inten- 
sified than is usual with advancing age; it is apt to be metallic; if the 
valve is implicated we have the appropriate murmur. 

Diagnosis: — When the diseased artery can be felt the diagnosis is 
easy; but when the disease is confined to the deeper arteries the diagnosis 
requires a careful study of the case. The disease is manifested early, 
however, by pulsation and tortuosity of the retinal arteries, and other 
ocular changes. The disease in the aorta may be indicated by the ring- 
ing metallic character of the aortic second sound. Stiffened radial arteries 
in a corpulent man, whose dyspnea on exertion cannot be explained by 
the condition of his heart, point to sclerosis of the abdominal vessels. 
A slow pulse with high tension and hypertrophy in such a person, if of 
sedentary habits, are significant. The development of feebleness of 
the heart after slight extra exertion is also indicative. The diagnosis, 



ARTERIOSCLEROSIS 435 

nowever, is often inferential, as fatty overgrowth may occasion ciosely 
analogous symptoms, and occurs in similar cases. We may guess at the 
existence of sclerosis of the pulmonary artery when an elderly working 
man, with stiffened arteries and right ventricle hypertrophied, suffers 
from chronic bronchitis and emphysema. 

Prognosis: — It depends upon the extent of the disease and the conse- 
quent interference with the circulation. The disease is progressive, 
admittedly incurable, but may be checked by suitable treatment. The 
more serious the interference with the nutrition of any part the graver 
is the prognosis. 

TreBtment: — Prophylaxis involves the early recognition of the pres- 
ence of the disease and such a regulation of the habits, diet, exercise and 
excretion as will lessen undue vascular strain and regulate vascular 
pressure. When the profession learns to appreciate the value of vera- 
trine the condition known as high tension will be less dreaded. The 
corpulent abdomen is to be reduced, the food restricted to the needs in 
quality and quantity, excesses in business are to be forbidden, and exercise 
and recreation prescribed in doses suited to the case. As a rule foods 
rich in lime, extractives and volatile oils, are objectionable. The patient 
must, however, be restrained if in his enthusiasm for reform he is apt 
to go too far and reform himself off the face of the earth. The habits 
of fifty years cannot be ruthlessly and radically altered like those of fif- 
teen. We need scarcely say that autotoxemia is to be prevented, and 
the bowels regulated with the utmost care; no injurious element must 
be allowed to circulate in the blood; no more work must be put upon an 
impaired heart, kidney or liver, than is absolutely unavoidable. 

The writer has for many years treated arteriosclerosis medicinally 
by the administration of the iodide of arsenic. This is one of the most 
active preparations known of arsenic and of iodine. Both these elements 
tending to cause irritation of the eyelids, we have in this a ready means 
of judging when full desirable effects of the drugs are being secured. 
Few patients will bear more than a milligram of this salt four times a 
day, given in solution, an hour before each meal and on going to bed. 
If after a week's administration the patient shows no signs of the drug, 
each dose may be gradually enlarged; but on the first sign of irritation of 
the lids the dose should be lessened until the irritation disappears; and 
the remedy continued as closely as possible to the irritation point 
without actually touching it. The remedy should be continued for at 
least a year. The explanation of its action is as follows: The influence 
of a remedy may be carried as far as extends the circulation hemic or 
lymphatic; a part at least of the disease is still intravascular, and this 



436 ACUTE AORTITIS 

we may reasonably expect to influence by drugs carried in the circulation. 
How much of the disease is intravascular we have no means of knowing, 
unless it may be by noting the effects of such treatment. Under the 
influence of this remedy it has been my good fortune to note the cessa- 
tion of further extension of the disease and the subsidence of a certain 
part of the developed symptoms. I may say that the treatment also has 
invariably won the confidence of the patient and that no difficulty has 
been experienced in inducing him or her to persist in the treatment as 
long as it has been deemed advisable. The reason the benefits of such 
treatment have not been recognized generally by the profession, is com- 
prehensible. The union of an absorbent like iodine, in its most potent 
form, with a remedy like arsenic which we believe favorably affects the 
nutrition of the circulatory tissues, is a rather nice application for these 
days, when drug treatment generally is so heartily despised; and the 
physician must have faith in the reasoning on which he founds the use 
of a drug, or he will not have the patience to persist in it for a year, and 
await the slow progress which alone can be depended upon to secure a 
cure in a disease whose development is as slow as this. The writer has 
in mind now the case of a lady, then seventy- three years of age, with 
marked symptoms of arteriosclerosis, including a perfect senile ring. 
She was treated as above described fifteen years ago, and remains healthy 
and hearty to this day, enjoying life, with no return of the serious symp- 
toms which then presented themselves. 

The symptomatic treatment consists especially in remedies, hygienic 
and medicinal, for the cardiac insufficiency. Strophanthin is probably 
the best heart-tonic. I have succeeded better in the use of this class of 
agents whenever there was coldness of the skin, indicating cutaneous 
vasomotor spasm, by adding atropine; or when the vascular tension was 
universally high by uniting veratrine to the heart-tonic administered. 
The diatetic regime and the other hygienic measures indicated are of 
such immense importance that here if anywhere the practician is par- 
donable for saying little as to drug treatment in order not to weaken the 
effect of his injunctions as to regulation of the habits. The union of 
high vascular tension with sclerosis and feeble or failing heart, presents 
peculiar difficulties to the therapeutist; and sometimes the most effective 
drug combination can only be ascertained by experiment. 

ACUTE AORTITIS 

This malady occasionally accompanies acute endocarditis. Only in 
France has the disease been detected independently. The inflamed aorta 



INFLAMMATION OF OTHER ARTERIES. 437 

is dilated, the inner coat roughened by minute thrombi, which when 
swept into the current; cause embolism. The process is too nearly iden- 
tical with that occuring in acute endocarditis to require separate descrip- 
tion. If ulceration occurs an opening may be made from the aorta into 
an auricle, a neighboring vessel or the pericardium. The disease may 
be an extension from the endocardium or may possibly occur independ- 
ent!)' in the course of an acute eruptive fever or other infection. 

The malady is usually latent or overlooked. The symptoms can 
scarcely be distinguished from those of endocarditis. The pulse, in in- 
dependent cases, would not be as weak as in the latter. Pain is felt under 
the manubrium, down the spine and sometimes in the left shoulder and 
arm. Oppression and anxiety may be felt; tenderness may be present 
in the intercostal spaces, to the left of the manubrium. Undue throbbing 
of the right subclavian has been noted. Difficulty on swallowing, cough 
and digestive disturbance, sometimes occur. 

The physical signs are indefinite. The right subclavian artery may 
pulsate more strongly than the left. The diagnosis is generally a matter 
of conjecture. When the pain resembles that of angina it differs from 
that disease in being persistent; the heart-sounds are normal, and the 
area of cardiac dullness is not enlarged as in endocarditis. 

The prognosis is bad. Embolism renders it still worse. Perfora- 
tion or rupture of the aorta is possible. 

When the disease is suspected the patient must be strictly confined 
to bed, and his strength sustained by scientific feeding. Pain may be 
relieved by morphine, hot or cold applications; vascular pressure should 
be depressed as far as it is possible by the use of vera trine; and other 
indications met as they arrive. 

INFLAMMATION OF OTHER ARTERIES 

Inflammation of single arteries may occur as an extension of disease 
from surrounding parts or from embolism. The usual infiltration takes 
place, the endothelium swelling, connective tissue developing under- 
neath it. Embolism is followed by thrombosis, the mass becoming or- 
ganized and obliterating the vessel, unless the embolus is septic, when 
an abscess results. 

No symptoms can be recognized unless in case of embolism, when 
an infarction is formed. When the vessel is occluded there may be, possi- 
bly, evidence of the disturbed circulation. Embolisms are denoted by 
pain, suddenly developing, with the coldness, numbness and cyanosis 
indicative of obstructed circulation. The physical signs are those of local 



438 ENDARTERITIS OBLITERANS. 

inflammation — heat, tenderness, pain, pitting on pressure and haraness. 
The diagnosis is made by the history and local symptoms. The prog- 
nosis depends upon the cause. When possible the affected part should 
be elevated, kept at rest and hot or cold applications made, while the 
bowels are kept clear and aseptic, and the patient's strength carefully 
maintained. Abscesses should be promptly evacuated when within reach. 

SYPHILITIC ARTERITIS 

When syphilis infects the arteries it occasions inflammation in patches, 
especially in the brain; these are grayish white or translucent. Some- 
times the vessel is obliterated, a gray cord remaining. In any case the 
vessel is narrowed and unless quite large is occluded. Small gummata 
form in the middle coat, replaced in time by cicatricial nodules. As 
these contract they cause pouchings of the inner coat, which are highly 
significant in the diagnosis. These may form the beginning of aneurisms. 
Constrictions are also formed by fibrous tissue developing in the outer 
and inner coats. The affection is most common in the cerebral arteries; 
next in the aorta and coronary arteries. It occurs in the tertiary period. 

Developing in the brain this malady causes obstruction of the circu- 
lation and symptoms of acute softening, loss of memory, vertigo, head- 
ache, epileptiform convulsions and mental confusion, sometimes followed 
by general paresis. In the aorta it causes sclerosis or aneurism; in the 
coronary arteries it causes angina pectoris; occurring anywhere else the 
symptoms are those of the obstructed circulation. 

The diagnosis depends upon the history of the infection to which the 
lesions may be attributed. The prognosis is bad, because the damage 
is usually done before the disease is recognized and the patient placed 
upon proper treatment. The treatment is that of syphilis of the heart, 
already described. 

ENDARTERITIS OBLITERANS 

We will not spend much time over this rare affection. It usually 
occurs in the smaller arteries of the foot or leg, in which the vessels are 
bound firmly together by a tough fibrous mass; the artery is converted 
into a firm cord, its lumen being occupied with a wide-meshed tissue. 
The process commences with the arterioles and may extend up as far 
as the femoral artery. The inner coat is hyperplastic, with new-formed 
connective tissue, with which is a delicate, thread-like intercellular sub- 
stance; in this blood-vessels appear. 



ANEURISM OF THE THORACIC AORTA 439 

The cause is unknown. It is more frequent in men, attacking the 
young and previously healthy; it may invade a single artery of the limb. 
The patient may have for years complained of pains in the limbs followed 
by paresthesia, numbness, formication, etc. At first the pain is relieved 
by rest, but as it increases the patient finds it impossible to use the limb, 
which feels heavy, causing lameness. When the artery is blocked gan- 
grene occurs in the area supplied by the vessel. It spreads upward rapidly, 
and unless promptly removed the patient dies of sepsis. The disease 
is progressive. The diagnosis is difficult in the early stage and can only 
be guessed at until the artery has been obliterated. We then have the 
absence of pulsation in it, with cord-like rigidity. This disease is more 
frequent before thirty; sclerosis after fifty. This is local, the latter more 
general. Gangrene develops from sclerosis in both legs in time; Rey- 
naud's disease is most frequent in still younger subjects, begins abruptly, 
and the parts affected are anesthetic. They are not rigid, nor are the 
vessels pulseless. The prognosis is bad, the malady never being recog- 
nized until it has proved destructive. No treatment has been evolved 
beyond the relief of symptoms, and surgical intervention at the earliest 
occurrence of gangrene. 

For information upon periarteritis nodosa, stenosis of the aorta and 
the pulmonary artery, and congenital smallness of the arterial system, 
the reader is referred to Babcock's and other classic treatises. 

ANEURISM OF THE THORACIC AORTA 

Aneurisms are classically divided into true, dissecting and false. The 
latter term describes a collection of blood that has escaped from an artery 
into the surrounding tissues, forming a hematoma. In a dissecting aneurism 
the inner coat is torn and the blood burrows between it and the middle 
coat, dissecting up the inner coat. Sometimes it again opens through 
it and the blood is discharged again into the vessel. In a true aneurism 
all the coats of the artery are dilated and form the coats of the aneurism. 
The dilatation may be fusiform or sacculate. In the former the entire 
vessel is dilated, in the latter only a part of its circumference gives way. 
The latter is the more common. As the aneurism enlarges the inner 
coat is lost, the muscular fibers of the middle coat degenerate, while the 
elastic elements become granular. This coat also may disappear leaving 
the wall of the aneurism composed only of the thickened, infiltrated ad- 
ventitia. The opening communicating with the aorta is small as com- 
pared with the sac. In the latter we find layers of light fibrin, covered 
with later deposits which are redder and less firm in texture. In this 



440 ANEURISM OF THE THORACIC AORTA 

way the cavity may in time be completely filled with coagula. While 
this may be termed a natural cure, the degeneration of the walls of the 
artery which caused the original aneurism will probably cause others, 
so that multiple aneurisms are not uncommon. The size may vary from 
that of a nut to that of a man's head; the shape of the larger aneurisms 
being irregular. All the structures compressed by the growing mass 
are affected by it. 

Etiology: — Arteriosclerosis, degeneration of the arterial walls, is the 
common cause, the coats giving way during the period of primary weak- 
ness before the fibrous hyperplasia has reinforced the vessel. Syphilis 
is also a cause of degeneration and of aneurism. The latter is rare before 
the 40th year. Men are the more liable, as more subject to the predis- 
posing causes and to muscular strain. Alcoholism tends to favor the 
degenerative processes, as well as to increase the liability to syphilis. 
Muscular strain and traumatism ean only affect an artery previously 
weakened by disease. Ulcerative endocarditis causing embolism usually 
accounts for aneurisms of peripheral vessels. 

Symptoms: — While small the aneurism may not cause enough trouble 
to attract attention. If it develops close to the aorta it may rupture into 
the pericardium and cause sudden death. In many cases the symptoms 
are indefinite. Others afford unmistakable evidences. These are due 
to the pressure of the enlarging sac upon the structures with which it 
comes in contact. 

Pain occurs early and constantly. If the growth of the tumor is 
toward the sternum the pain is early, constant, neuralgic, sharp and lancin- 
ating, or dull and aching, boring, grinding, cutting, burning, etc. It 
may be radiated along the intercostal nerves to the chest, neck, arms, 
etc. Tender areas may be found along the left of the sternum. Less 
pain is occasioned by growth inwardly, the pain is duller and less diffused, 
but dyspnea is caused by pressure on the bronchi. Besides the constant 
pain there are periods of severer suffering, when the patient exerts him- 
self or assumes some certain attitude, which probably causes pressure 
upon a sensitive point. Pain arising within the sac may be increased 
by a rise in the vascular tension, pressing upon a sensitive sac wall. Relief 
ensues when the intrinsic pressure is relieved by escape from some sur- 
rounding constricting tissue. 

Dyspnea results from pressure on the bronchi, trachea or lung. Irri- 
tation of a recurrent laryngeal nerve gives rise to distressing paroxysms 
of laryngeal spasm. The esophagus is apt to be simultaneously affected. 
Stridor often attends. Cough is usual, of varying type. Pressure on 
the trachea causes a harsh, strident cough — frequent in aneurism of the 






ANEURISM OF THE THORACIC AORTA 441 

transverse arch. One variety is termed the "goose cough." Paralysis 
of a vocal cord causes a toneless, muffled cough. The sputa consist of 
mucus, serum, pus; if gangrene occurs it is offensive. Blood may come 
from tracheal granulations, congested bronchi, necrotic pulmonary tissue, 
or from the sac "weeping." 

Dysphagia occurs with aneurisms of the transverse and descending 
aorta, whenever the esophagus is compressed. Food seems to lodge 
at the obstructed point, and if low down may be regurgitated. If portal 
stasis occurs there will be digestive troubles. 

Pressure on the venae cavae is less frequent but may be so great as 
to cause the opening of collateral channels for circulation. The cuta- 
neous veins dilate and general or local edema appears. The pulses become 
unequal, that compressed being delayed. The heart may be pushed 
to one side. 

Aneurism of the Ascending Aorta:— H this is close to the aortic ring 
in the sinus of Valsalva, it is apt to elude discovery until it breaks into 
the pericardium, causing sudden death. Arising from the convexity 
it may become very large; if it grows forward a pulsating tumor appears 
to the right of the sternum, in the second and third intercostal spaces. 
The bone is eroded and in time the sac penetrates beneath the skin. The 
pleura may be penetrated and the lung compressed or collapsed. 

Arising from the convexity, the superior vena cava is compressed, 
and the aneurism may open into this vessel. Pressure on the right sub- 
clavian vein causes congestion and edema of the parts drained by it. 
Pressure on the right recurrent laryngeal nerve irritates and then 
paralyzes the right vocal cord; the heart is pushed down and to the left, 
and dilatation of the aortic ring causes relative incompetency of that 
valve. This induces left ventricle hypertrophy. 

Aneurisms from the concavity sometimes appear at the left of the 
sternum, displacing the heart down and to the left. 

Aneurisms of the Transverse A re h:— These generally develop back- 
ward, pressing on the trachia and esophagus, causing dyspnea and dys- 
phagia. Paroxysmal cough and stridor are very common. If the sac 
projects forward the tumor appears at the right of the upper sternum, 
which is eroded. These aneurisms may become enormous, invading 
both pleura. They compress the left recurrent laryngeal nerve and 
bronchus, first irritating the nerve and then paralyzing it. Distressing 
spasm of the larynx is thus caused; swallowing becomes difficult also, 
from spasm of the muscles of deglutition. Angina pectoris may occur 
from pressure on the cardiac branches of the recurrent; or the voice is 
affected. Pressure on the left bronchus causes retraction of the lungs, 



442 ANEURISM OF THE THORACIC AORTA 

the side becoming immobile, with tympany and weak breathing sounds. 
The side shrinks as the lung retracts; and, collapsing, percussion shows 
dullness and absence of respiration; secretions may be retained, causing 
various rales, or bronchorrhea or bronchiectasis develop. 

The thoracic duct may be compressed. If the innominate or carotid 
artery is compressed the pulses become unequal, that on the compressed 
side lagging behind the other. Pressure on the sympathetic nerve causes 
a dilated pupil at first, a contracted one later. Tracheal tugging may 
be developed. The aneurism may rupture into the trachea. 

Aneurism of the Descending Arch:— The growth is generally back- 
ward or to the side of the thorax; but occasionally it appears at the left 
of the sternum. The symptoms caused in the left lung are similar to 
those described in the preceding paragraph; dysphagia occurs, and erosion 
of the third to the sixth dorsal vertebrae results. When the spinal cord 
is compressed, paraplegia appears. 

Aneurisms of the Descending Thoracic Aorta:— These usually develop 

near the diaphragm, and are obscure. Dull pain may be felt in this region, 
with impaired resonance and feeble respiration in the area occupied by 
the tumor. Dysphagia and regurgitation are common, but respiration 
is little affected. Other pressure symptoms do not arise, excepting from 
some pressure upon the lung as the tumor enlarges. Other portions of the 
aorta may become involved in the disease. 

Physical Signs: — The patient may appear healthy but develops a 
cachexia in time; the tumor, pulsating or quiet, may be detected at some 
point of the surface, to the right or the left of the upper sternum, or above 
it; or between the scapulae below the fourth dorsal vertebra. The skin 
may be smooth and shining, and the prominence may become quite large. 
It is apt to end abruptly, something like a watch-glass set upon the skin, 
the covering of the prominence being red, or cyanotic, or shining, the 
skin above it being fused with any other covering the aneurism may have. 
The capillaries may be enlarged, or the veins distended or tortuous; edema 
and congestion of one or both arms may appear, including the corres- 
ponding half of the neck. Pulsation may occur in abnormal situations, 
the diastole being marked by a collapsing flap; the heart is displaced, 
generally downward and to the left, but sometimes forward. The motion 
of respiration may be lessened or absent on half the thorax, usually the 
left, and the side may be evidently retracted; one pupil may be immobile, 
dilated or contracted; sweating of the head is common, sometimes uni- 
lateral. 

Bimanual palpation is a useful means of judging the pulsation; this 
may not be visible even in a large projecting mass if it is well filled with 



ANEURISM OF THE THORACIC AORTA 443 

fibrinous deposits; if empty the pulsation is a slow heave, expansile and 
followed by collapse of the thin wall. A diastolic shock may be felt from 
the recoil of the elastic wall of the sac, and quite rarely a thrill may be 
detected. The pulse at the two wrists may be unequal and one lagging 
slightly behind the other. The liver may be congested. 

The tracheal tug is a distinct downward pull of the trachea, caused 
by the stroke of the aneurism against the bifurcating trachea or a bronchus. 
It may be demonstrated with a wide aortic leakage but is most marked 
in aneurism of the transverse arch. Have the patient raise his chin, strongly 
extending the neck; insert the tips of the forefingers below the cricoid 
cartilage, and pull the larynx gently upward; the trachea will be felt to 
be jerked distinctly downward with each stroke of the ventricle. 

Percussion is an important means of demonstrating abnormal areas 
of dullness. The most important point is the right infraclavicular region, 
close to the sternum; it may also detect displacement of the heart. 

If the sac is filled with coagula auscultation will not develop a bruit; 
otherwise an abnormal murmur may be audible over the sac. Either 
of the normal heart-sounds may be intensified, diminished or impure. 
Babcock speaks of a loud peculiarly ringing second tone heard over the 
tumor or but one cervical artery. A distinct bruit may accompany the 
second sound, or there may be a double to-and-fro murmur widely dif- 
fused. Occurring close to the heart, abnormal murmurs are less sig- 
nificant than when heard at a distance. The normal heart-sounds may 
be transmitted much farther than usual. Bruits may arise in the sac 
itself, but are probably transmitted from the heart and modified by the 
conditions obtaining in the sac. Sometimes the bruit can be detected 
when the patient holds the bulb of the stethoscope between his teeth, 
his lips being closed around it. Abbott of St. Paul has described a case 
in which this was the only evidence of aneurism discoverable. 

Diagnosis: — This is easy enough when an external tumor shows 
the expansile collapsing pulsation; while still small it may be impossible 
to make a positive diagnosis. The history, occupation, age and sex; 
with symptoms showing pressure within the thorax, such as the pain as 
described, dyspnea influenced by posture, clanging cough also influenced 
by posture, and difficulty of swallowing, are the principal features. We 
may also find bulging in an aneurismal area; dullness, a displaced heart, 
and the altered signs of auscultation, especially a harsh aortic systolic 
bruit with a clanging second sound, which may be split or doubled and 
is most plain over an abnormal dull area or in one cervical artery with 
a diastolic shock. The aneurismal pulsation may equal in intensity the 
apex beat. Tracheal tugging is strong evidence. 



444 ANEURISM OF THE THORACIC AORTA 

Thoracic cancer is sometimes indistinguishable from aneurism; in 
the former the growth is generally more rapid, the decline in strength 
and weight also. The pulsation differs, as well as the bruits; pulsation 
is not expansile in a solid tumor, being due to the impulse from an artery 
or the heart underneath it; but the same is true of an aneurism filled up 
with coagula. The tracheal tug is not present; the growth does not appear 
in the usual seats of aneurism. It never changes its direction with sud- 
den alteration in the symptoms, nor does it cause a symmetry of the pulses; 
though it is conceivable that in some cases it might do so. Malignant 
tumors here are generally secondary, or present implication- of glands 
in the axilla or neck. 

Abscess in the mediastinum develops suddenly, with considerable 
pain before pressure is manifested. Fever occurs early, and there are 
no special murmurs. 

Pulsating empyemas are exceedingly rare and may occur in children. 
The history and physical examination usually explain the case. In doubt- 
ful cases the x-ray offers a reliable means of decision. 

The prognosis is very bad. Spontaneous cure is very rare, and here 
the surgeon fails to make good. The progress of the disease is irregular 
and may be varied by remissions. When the sac develops externally, 
the course may be rapid; ten years is a long limit, but has been largely 
surpassed. Death may be due to rupture of the sac, but is more frequently 
due to pressure. 

Treatment: — The natural or spontaneous cure occasionally occurs 
in small sacculated aneurisms with a narrow opening into the aorta. Such 
a sac may fill up with fibrin, which becomes organized. We seek to 
imitate and favor this method by placing the patient in the best condi- 
tions for its occurrence. For this purpose the first indication is rest; the 
patient is confined to his bed, absolutely, nutrition being sustained by 
massage. Vascular tension is reduced to the lowest possible point. This 
is accomplished; first, by reducing the bulk of the blood, through the 
medium of the dry diet and other measures fully described in the treatment 
of cardiac insufficiency. We also invoke here the potent influence of 
veratrine, the safest and most effective agent as yet developed for sus- 
tained lowering of vascular tension during prolonged periods. The 
diet should consist of light, easily digested but nutritious food; it is not 
necessary to confine the patient to brea,d, butter and milk; on the con- 
trary, meat powders may be used, with abundance of gelatin, to favor 
coagulability. The effects of iodide of potassium have never been satis- 
factorily explained. It does not act as an antisyphilitic, or altogether 
by relaxing vascular pressure, but its use has been confirmed by clinical 



ANEURISM OF THE THORACIC AORTA 445 

experience in many instances. A typical case occurred in the writer's 
practice. The aneurism was in evidence, a pulsating tumor appeared 
in the second and third intercostal spaces, to the right of the sternum; 
the pulsation collapsing quickly, the area dull on percussion, the pressure 
effects unmistakable. Dyspnea was great; the patient was unable to 
leave his bed. He was placed upon the dry diet, with potassium iodide 
up to 120 grains a day. During the three months he remained under 
the writer's treatment he improved so greatly that physicians then ex- 
amining the case for the first time were unable to make the diagnosis of 
aneurism, although all those who saw the case when it came under treat- 
ment considered the diagnosis beyond question. During this period 
the regime w r as so far relaxed that by the end the patient walked a mile 
in a day without discomfort. The termination of the case, unfortunately, 
is unknown; but there seemed no reason why the improvement thus 
happily inaugurated should not continue under the same circumstances. 

The above measures usually result in speedy relief from the suffering, 
without the employment of anodynes. Imminent danger, from vascular 
tension too high for safety, may require venesection. When the tumor 
has appeared at the surface ice may be applied with advantage, while 
the patient is lying down. If he goes about, some mechanical means 
may be contrived for the protection of the outgrowth against injury. 
The bowels must be kept regular and straining at stool must be abso- 
lutely prevented. In the last days morphine and chloroform should not 
be withheld. 



PART VI 



DISEASES OF THE DIGES 
TIVE SYSTEM 



I. DISEASES OF THE MOUTH 



STOMATITIS 



The disease is a superficial, catarrhal inflammation, usually caused 
by mechanical irritants, hot, cold or sharp foods, chewing toothpicks, 
tobacco, carious teeth, mercury, and especially the use of the toothbrush, 
and the habit of leaving false teeth in the mouth for long periods. Ty- 
phoid and the eruptive fevers, digestive maladies and morbid processes 
extending from the nasopharynx are causative. 

The inflammation commences with burning or itching at one point, 
with swelling and dryness, the membrane being puffy and tender. The 
parts affected may be marked by pressure of the teeth. The tongue pap- 
illae enlarge and little vesicles form on the mucosa, which break leaving 
erosions that may deepen into ulcers. The taste is perverted, sapid foods 
cause pain, and cold fluids are craved. The saliva is acid until ulcers 
form, and contains disintegrating epithelium, leucocytes and a few red 
cells. Various microorganisms are also present. General symptoms 
are those of any accompanying malady. The course occupies a week. 
The diagnosis is made' by inspection. Clear the bowels and regulate the 
digestion and diet. Stop all irritations, and substitute rubbing with a 
pad of absorbent cotton for the germ-laden, lesion-producing toothbrush. 
Instruct the patient to place false teeth in a cup of water over night, with 
some volatile aromatic antiseptic such as a menthol tablet. Employ any 
mild non-toxic antiseptic lotion as frequently as possible in the mouth, 
or sucking a grain tablet of any sulphocarbolate salt will answer. Dry 
any ulcers present and dust with iodoform — yes, its odor is bad, but noth- 
ing else so certainly, promptly and permanently stops the pain. Tender 
and ulcerated spots from the pressure of tooth plates should be penciled 



448 APHTHAE 

with tincture of benzoin daily. The gums and mucosa are firmed by 
using a 1-6 grain granule of berberine as a lozenge seven times a day. 
Cut out the potassium chlorate — it has caused fatal suppression of urine. 
Small and frequent doses of iron phosphate and quassin aid convalescence 
especially if the patient will use them as lozenges to secure the local as 
well as the general effect. 

APHTHAE 

Aphthous stomatitis occurs most frequently between the ages of two 
and six years, occasionally in adults. Bad hygienic influences, malnu- 
trition, dentition, gastric affections, debility from any cause, and eruptive 
fevers are causes. Local irritation, chemic or bacterial, excites attacks. 

Vesicles appear on the edges of the tongue, inside the lips or cheeks, 
from a pinhead to a pea in size, soon breaking and leaving ulcers, round 
or oval, surrounded by inflamed zones. The tenderness prevents rest 
or feeding, salivation attends, the breath is bad, and there is some fever. 
The digestion is always disordered and the bowels are constipated or 
diarrheic. The ulcers may become confluent, especially in infective fevers. 
In Bednar's aphthae large white patches are seen on both sides of the 
hard palate near the teeth and may involve the bone. Riga's disease is 
a form found in southern Italy, a raised gray swelling on the frenum and 
under surface of the tongue, appearing after the eruption of the lower 
incisors. The duration of ari attack in within a week unless prolonged 
by successive crops. The diagnosis is from thrush. 

Confluent forms are more troublesome. Bednar's form is usually fatal. 

Remove all irritations, make the food absolutely bland and tasteless, 
empty the bowels and keep them disinfected, and require absolute asepsis 
in all utensils employed in feeding the child. The treatment of stomatitis 
is applicable here. As the malady is one of debility local vital incitation 
is indicated, and the ulcers should be painted with nuclein solution several 
times daily. A grain tablet of calcium sulphocarbolate may be used as 
a lozenge every half hour by childreen old enough to he controlled. Others 
should have zinc sulphocarbolate solution applied as a lotion as many 
times a day as possible. Five grains in an ounce of cinnamon water is 
an average strength to employ. Confluent or spreading ulcers may be 
touched with spirit of turpentine daily, as at once antiseptic and stimu- 
lant. Beware of applying vitality destroyers to dying tissues. The diet 
should be nutritious and easily digested, and vital incitation by the tonic 
arsenates and nuclein kept up from the first. Pure open air and sunlight 
are powerful aids. 



ULCERATIVE STOMATITIS. 449 

MEMBRANOUS STOMATITIS 

The intenser inflammations of the mucosa may produce false mem- 
brane, croupous, diphtheritic, gonorrheal or syphilitic. Forms secondary 
to ordinary diphtheria are treated in connection with that malady. 
Strepto- or staphyloccocus infection may be present. Venereal 
infections are seen in newborn infants. The symptoms are those 
of stomatitis, with the presence of pseudomembrane, which if removed 
reveals deeper ulceration than occurs in the preceding forms. The sup- 
portive treatment advised is still more imperatively indicated here. Loz- 
enges are far more effective than lotions, as their period of action may be 
made almost continuous in children old enough to comprehend the need. 
In younger ones the physician may succeed in rendering his antiseptics 
pleasant enough to be thus used. 

ULCERATIVE STOMATITIS 

Children from 3 to 8 are most affected; in damp weather, unhygienic 
surroundings, illy nourished, with poor vital resistance, and the dirt and 
squalor of city slums. Cachectic states, and local irritations such as are 
supplied by the teeth, favor the attack. Almshouses, jails and barracks 
are sometimes the scene of epidemics. Mercurialism, scurvy and other 
toxic states favor its occurrence. The specific cause is one or many 
microorganisms, taking oil malignancy under such conditions. It is con- 
tagious and may be conveyed in milk . Ulceration commences at the 
edges of the lower incisor gums, spreading to the cheeks and lips, the 
mucosa deep red, spongy and bleeding, sloughing deeply, teeth loosening 
and even the bone being attacked and necrotic, salivation free and dis- 
charges fetid, mastication and sometimes deglutition impossible. The 
tongue swells, also the submaxillary glands. Discharges swallowed cause 
nausea and vomiting, and even diarrhea. The cachexia and debility are 
increased rapidly. More or less fever is present. The course is acute, 
ending within a week unless protracted by necrosis, etc. A neurotic form 
occurs in elderly women and lasts indefinitely. The diagnosis is made 
by the local conditions, fetor of discharges and cachexia. The prognosis 
depends largely on the treatment. Patients should be promptly isolated, 
and the hygienic influences made the best possible. Feed up to the limit 
of nutrition and digestion, foods readily taken and assimilated, raw meats, 
turtle soup, clam broth, junket, fresh fruit juices, raw eggs, cafe au lait, 
given every two hours in full doses with artificial digestants. Potassium 
permanganate solutions as strong as can be borne are useful, and the em- 



450 THRUSH 

ployment of antiseptics should be as powerful and continuous as the case 
admits. Here again the application of stimulant-antiseptic volatile oils 
and nuclein locally is urgently required. Pads of linen containing char- 
coal may be placed in the mouth to absorb the odorous discharges, but if 
possible use antiseptics whenever the fetor returns. 

We prefer the aromatic disinfectants to peroxide and the destructives 
of all sorts. Pencil the ulcers with turpentine, or cinnamon oil, once a 
day and apply iodoform when needed to alleviate suffering. Apply nu- 
clein to all ulcers and dying tissues three times a day, or when possible 
continuously. The writer has witnessed such good effects from it when 
applied to tissues on the verge of dying and rescued by the local rein- 
forcement of vitality that he urges this remedy on his readers. Chlorine 
water is a most useful local disinfectant and stimulant also and may be 
applied as a lotion to the whole mouth every one to three hours. Do not 
extract loose teeth; they may be preseved. Necrosed bone should be 
removed. As soon as the acuter symptoms subside begin the use of ber- 
berine granules as lozenges for their local effect in contracting the relaxed 
tissues. These may be used almost continuously with advantage. Potas- 
sium chlorate has a great repute in this and other buccal maladies but 
we look upon it as a doubtful and dangerous drug, and only advise it as 
a means of preparing chlorine solution, as described in the chapter on 
diphtheria. 

THRUSH 

A disease of infancy, with digestive disorder, bad hygiene and bad con- 
stitution, inherited cachexia or following the eruptives. The specific 
germ cause is the saccharomyces albicans with which other organisms may 
be associated. From its rounded spores develop long mycelial threads 
with torula cells budding from the ends. The threads penetrate the 
deep mucous layers and enter the mucous glands. The growth requires 
an acid medium and unhealthy membranes, such a condition as is fur- 
nished by these patients with badly cared-for milk leaving its souring 
remnants in the mouth. The local destructive effects of sugar and its 
fermentability make it a potent auxiliary. The mucous membrane is 
1 vid and inflamed, and on the surface appear the raised patches of thrush, 
first on the tongue or the inside of the cheeks, spreading at the edges 
till they coalesce and may cover large secti ns of the mucous tract, 
extending to the pharynx and even to the larynx and stomach. They 
look like bits of curdled milk, but are found to be adherent. They may 
become loose or penetrate the membrane deeply. The saliva is acid. 



NOMA: GANGRENE OF THE MOUTH. 451 

There is always digestive trouble, dyspepsia and diarrhea, and evidences 
of the causal malady. 

The diagnosis is made by the microscope, though aphthae may be 
distinguished by the presence of salivation, adherent deposits, ulcers, 
small and separate patches, herpetic vesicles at the start, tenderness of 
ulcers, as well as absence of the mycelial growth. The prognosis of 
thrush is good, but its advent in the course of cachexias is ominous. 

The disease is preventable by keeping the mouth and the milk, bot- 
tles, tubes, etc., in proper cleanliness. Alkaline washes are useful, of 
lime or soda water; sugars and starches forbidden, and lime water added 
to the milk. Any mild acid antiseptic is curative, a weak solution of 
hydrochloric or lactic acid being suitable. Sweeten with saccharin or 
glycerin. Chlorine water suits bad forms. The esophagus may be 
so obstructed as to necessitate forcible catheterization of this tube to 
introduce nutriment. The tonic-dietary regime is indicated, with cor- 
rect hygiene and the treatment of accompanying maladies. 

NOMA: GANGRENE OF THE MOUTH 

Gangrene beginning on the inside of the cheeks may spread to the 
jaw and lip. The vessels are occluded by thrombi, the connected glands 
are soft and swollen, and pulmonary infarctions may occur. Metastatic 
myocardial infiltration, membranous colitis and pericardial suppuration 
have been described. Gangrene of the gums sometimes occurs in new- 
born babes. 

The malady is more common in girls, from 2 to 5. It occurs in low 
wet lands, in the slums, usually secondary to scarlatina, smallpox, typhoid 
fever, whooping-cough, and especially measles. Diphtheria and other 
microbes have been found. 

On the inside of the cheek appears a dark, ragged, sloughing ulcer, 
appearing and spreading painlessly. This may be preceded by an in- 
duration with violaceous tint of the cheek. Over this a small blister or 
vesicle forms, which covers the black eschar of gangrene. An offensive 
ichorous discharge follows with shreds of the breaking down tissues. 
The fetor is extreme. The malady may involve half the face and extend 
to the bones, but rarely crosses the median line. Profound prostration 
supervenes. The temperature may rise to 104 F., with delirium and 
dropsy, preceded by dyspeptic disturbances. Sometimes there is diar- 
rhea but in other cases the digestive functions are remarkably little affec- 
ted, the child taking food well when the gangrene is active. Gangrenous 
disease of the pulmonary tract may follow contamination, or colitis, or 



452 MERCURIAL PTYALISM 

genital gangrene. If recovery occurs the gangrenous tissues separate, 
granulation commences, and cicatrization follows, with deformity. 

Diagnosis is unmistakable. Anthrax occurs in adults, beginning on 
the skin, and the anthrax bacillus is present. Ulcerative maladies of the 
mouth are not gangrenous. Recovery is rare. 

The case should be isolated strictly. Success in treatment lies in the 
earliest recognition of the disease and its prompt and effective manage- 
ment. Cauterize with the best agent accessible, the actual or Paquelin 
cautery being preferable. Remove loose and dead tissue and thoroughly 
cauterize the base of the excavation, then dress with spirit of turpentine 
or other volatile oil. The mouth washes should likewise be aromatic 
antiseptic. Nuclein should be applied continuously and given internally 
in maximum doses, as well as the tonic arsenates of iron, quinine and 
strychnine. The older practicians believed that full doses of the tincture 
of the chloride of iron — a dram every four hours for an adult — possessed 
superior powers as an inciter of vitality — and this has not been disproved. 
The advice as to diet given in the preceding section may be repeated here. 
Antitoxin will of course be employed in diphtheritic cases, and in strep- 
tococcic, forms Marmorek's serum may prove effective; but dependence 
should not be placed on such remedies to the neglect of others. 

MERCURIAL PTYALISM 

Certain persons are unusually susceptible to toxic effects from mer- 
cury. Those who work with this metal are also liable (See Mercurial Poi- 
soning, Part X). The first evidence of its toxic action is usually a metallic 
taste, then one or more teeth seem too long and to project from their sock- 
ets, while the gums become soft and tender. Salivation follows, the 
breath is fetid, tongue and buccal mucosa swollen, and mastication pain- 
ful. The malady may go on to ulceration and even extend to the teeth 
and bones of the jaw, which may necrose. There is some fever, more 
or less liquefaction and absorption of tissues, diseased and normal, as 
described in Section X. 

The diagnosis rests on recognition of the cause, which may be de- 
tected by inquiry as to occupation. The prognosis is good 

Stop the mercury. Stop salivation by the use of atropine enough 
to dry the mouth. This is also preventive when it is desirable to push 
mercury to the limit. Treat the stomatitis as advised in preceding sec- 
tions. Mercury may be eliminated by the use of iodine preparations, 
none as good as calx iodata, ten grains a day, as the lime is needed as a 
reconstructive. The first effect may be a return of ptyalism, as the iodine 



ACUTE GLOSSITIS. 453 

renders the mercury soluble. Prof. George F. Butler advises for the local 
and general relaxation the use of tincture of iron, gtt. 10, and potassium 
chlorate, gr. 1, in a dram of water and glycerin, to be allowed to lave the 
buccal mucosa and then to be swallowed, this repeated every two hours. 
The value of berberine used locally as previously advised is never better 
shown than in this form of stomatitis. Baths are useful, with rubbing. 
Calcium lactophosphate may be given for months, gr. 10 daily, to restore 
strength to the cell walls. 



II. DISEASES OF THE TONGUE 

ACUTE GLOSSITIS 

The predisposing causes are obscure — poor health and cachexias 
predispose to everything morbid. Excitants are stings and bites of in- 
sects, and corrosives or burns. Slight abrasions open the way for 
microbic invasions. The toothbrush is probably a frequent source of 
such injuries. 

The onset is sudden and the progress rapid, the tongue swelling until 
it protrudes from the mouth, sore and aching, coated, dry and cracked. 
Stomatitis and salivation usually attend; talking, swallowing and even 
breathing may be difficult, and suffocation may threaten. The cervical 
and sublingual glands swell. Suppuration may follow, the symptoms 
being obscure until the pus makes its way to the surface. The inflam- 
mation reaches its acme in about three days and subsides in a week. The 
prognosis is good. 

Small pellets of ice allowed to melt in the mouth are grateful. Any 
aromatic water makes a useful mouth wash, mint water being especially 
pleasant to the patient. Use a weak alkaline solution, as one of 
borax or sodium bicarbonate. If edema is great superficial scarifi- 
cation may be of value. Keep the bowels empty with salines and aseptic 
with sulphocarbolate of zinc. Ice bags or cold compresses to the neck 
are of value. Suppuration may be prevented and resolution hastened 
by quickly saturating the patient with calx sulphurata, half a grain every 
half hour; dropping five drops of nuclein solution on the tongue every 
hour also. Deplete the blood and reduce tension by enemas of satur- 
ated salt solution, half a pint every four hours, quite cold. The rectum 
may be utilized for feeding, but abstinence is useful here and rarely ob- 
jectionable. Tracheotomy may be requisite to prevent choking. Steam- 
ing has been advised and probably is of some small value. 



454 ANGINA LUDOVICI. 

CHRONIC GLOSSITIS 

The causes are, acute attacks, the use of tobacco by chewing or smok- 
ing, strong liquors, and irritating foods. The irritation of jagged teeth 
and the discharge from caries are frequent causes. 

The tongue is smooth and red, generally or in patches, furrowed, 
and the general health impaired. The cause is to be found and removed; 
the diet and bowels regulated, teeth put in order. An effective local appli- 
cation is corrosive sublimate a grain to the ounce of distilled water, paint- 
ed over the affected patch twice a week. In the intervals apply nuclein 
solution twice a day. Mild antiseptics are useful, such as a two-grain 
calcium sulphocarbolate tablet sucked like a lozenge every four hours. 

GLOSSITIS DESICCANS 

rCare, chronic, cause unknown. The tongue is divided into areas by 
deep furrows, in which food lodges and causes irritation and ulceration 
Let these be cleaned carefully, thoroughly and without undue rudeness 
after each meal; then pencil the furrows with tincture of benzoin and 
use berberine granules as lozenges. The malady is not easily cured 
but the foregoing has succeeded. 

TYLOSIS LINGUAE 

The glossal epithelium projects in irregular areas of hyperplasia, 
maplike, of unknown cause and persistent. It does no harm except by 
frightening the possessor with the idea of serious disease. 

LEUCOPLAKIA ORIS 

White or bluish, scarlike patches appear on the buccal mucosa, the 
sides of the tongue, coming and going, the cause unknown. Syphilis 
and the pipe have been suspected. There are no symptoms unless ulcera- 
tion occurs. In children patches appear resembling ringworm. Paint 
with tincture of benzoin three times a week, and on alternate days with 
tincture of iodine if not sore. See to the teeth. 

ANGINA LUDOVICI 

The malady is most often seen with or after scarlatina or diphtheria, 
and is probably a streptococcal infection, It may come from injury. 



SALIVATION: HYPERSECRETION. 455 

An abscess forms under the tongue, the whole floor of the mouth and the 
neighboring parts of the neck swelling rapidly. Pain and other inflam- 
matory evidences are marked, mastication, talking and swallowing are 
impaired, and alarming dyspnea may result. Fever is marked and de- 
bility may be rapidly induced, of the typhoid or the septic type. Reso- 
lution is unusual and the pus may burrow if not promptly evacuated. 
It is a dangerous malady. It should not be mistaken for an aneurism, 
or vice versa. 

Drain the bowels quickly and saturate with calx sulphurata, applying 
nuclein to the tongue, five drops every hour. Tracheotomy may be re- 
quired. Open quickly when pus is found to have formed. Support by 
rectal feeding, and sustain by full doses of strychnine hypodermically. 

III. DISEASES OF THE SALIVARY 

GLANDS 

SALIVATION: HYPERSECRETION 

This rarely occurs apart from the maladies described above. It has 
occurred from emotional causes. The writer reported a case that had 
lasted five years, following the insertion of an amalgam filling in a 
tooth, the patient having already some gold fillings. The amalgam 
was removed and the salivation ceased at once. Presumably the 
metals had set up a galvanic current which was the excitant. There 
may have been an unusual condition of the saliva, since such multiple 
fillings are usual and do not as a rule cause salivation. In cases due to 
transitory causes the remedy is atropine. 

Xerostoma, dry mouth, is due to neural influences, emotional, or to 
mouth breathing. It may occur in diabetes. The membrane may be 
red and glazed, cracked, the teeth crumbly. The remedies are muscarine 
or pilocarpine which excite salivary flow, with irritant masticatories such 
as bits of aromatic root like calamus. In cases of centric origin give 
zinc phosphide, gr. 1-6 four times a day for a week. In the mouths of 
glassblowers may be found opaline plaques, dilatations of the cheeks 
and of Steno's duct, or contractions of the cheek muscles, with 
impaired hearing. The parotids may be emphysematous and crepitant. 

In septic maladies the parotid gland occasionally is infected and sup- 
purates. It is an unfavorable omen. The diagnosis may be made 
by the swelling of the gland, and fluctuation. It should be promptly 
and freely opened and drained, after disinfection. Strong supportive 
measures are indicated. 



456 ACUTE TONSILLITIS. 

Chronic, symmetric enlargement of these and the lachrymal and other 
salivary glands has been recorded. This may be secondary to mumps, 
pharyngeal or renal disease, or to lead or mercury poisoning. 

IV. DISEASES OF THE TONSILS 

ACUTE TONSILLITIS 

Inflammation may affect the mucous surface, dip into the follicles 
or extend to the parenchyma. The surface may be red and swollen, 
covered with soft exudate, which fills also the follicles, or the stroma in- 
filtrated and suppurating. The exudate consists of epithelium, pus cells 
and debris, with cholesterin, various microorganisms in older specimens, 
becoming cheesy when retained and sometimes chalky. The pus may 
burrow deeply behind the gland. Herpetic vesicles sometimes appear, 
break and leave thin adherent membrane. The mucosa may slough, 
separating by ulceration. 

Tonsillitis occurs most frequently in early youth, in boys, in the spring 
and in strumous or rheumatic persons. In fact, we now look upon ton- 
sillar inflammation as the initial microbic invasion that later develops 
acute rheumatism. Each attack predisposes to subsequent ones. Ex- 
citants are, exposure resulting in taking cold, inhalation of irritant gases 
or foul air, septic influences, mechanical or chemical irritants, and es- 
pecially the settling of a swarm of microorganisms on the tonsils and 
germination in the crypts. 

Acute Catarrh: — This accompanies catarrhs of the soft palate and 
pharynx. It begins with an itching spot, which is reddened and swollen, 
spreading at the edges, causing difficulty in swallowing, pain radiating 
to the ear and angle of the jaw. Cough, salivation and fetid breath are 
less common than when the deeper structures are implicated. A loose 
soft exudate may cover the surface. Some fever attends. The attack 
is sudden, lasts a few days and rapidly subsides. The middle ear may 
be affected. 

Acute Follicular Tonsillitis:— In addition to the symptoms displayed 
by catarrh the disease penetrates to the crypts, from which plugs of thick 
exudate project, sometimes forming little pus collections or ulcers. Both 
sides are affected. The tonsil and lymphatic glands are swollen and 
the swelling may be felt and seen on the surface of the neck. The at- 
tack may begin with a chill and the fever is high for the extent of tissue 
involved. Aching of the head, back and limbs attends, with anorexia, 
heavy urine and depression. The attack usually subsides within a week. 



ACUTE TONSILLITIS 457 

Abscesses may form and burrow, sequences may be pericarditis, endo- 
carditis, pleurisy, nephritis, erythema nodosum or other cutaneous 
disorders. The exudate may form foul smelling plugs that may be 
pressed out. 

Quinsy. — Parenchymatous tonsillitis occurs mostly in young adults. 
The throat is dry, swallowing difficult, pain in the ears severe, voice husky, 
and hawking brings up a little adhesive mucus. If pressure is exerted 
on the larynx dyspnea may be marked. The tonsils are swollen and 
may meet in the median line. They are red, firm, often covered with 
thick exudate. The submaxillary glands are swollen and tender. It 
is often impossible to separate the jaws enough to introduce food. With- 
in three days pus forms and great relief follows its discharge. Resolu- 
tion occurs, rarely spontaneously, with greater frequency as treatment is 
instituted early and effectively. The fever is often quite high, the pulse 
correspondingly fast, the headache severe, sometimes delirium and con- 
siderable prostration. Resolution sets in after three days in children, 
later in adults. Ten days covers the usual attack. Pus may burrow 
deeply and appear at the clavicle. Paralysis of the soft palate and phar- 
ynx may remain. Chronic enlargement frequently resu-.cs from repeated 
attacks. 

In the necrotic form the constitutional symptoms are marked, the 
cervical glands less enlarged. It is difficult to distinguish from diph- 
theria, which is in fact sometimes present. 

The diagnosis from diphtheria is not always possible, but tonsillitis 
presents a soft, yellowish deposit beginning at the mouths of follicles, 
easily removed, leaving an intact surface, never extending beyond the 
tonsil, not quickly if at all reforming after removal, with high fever for 
a day or two only, falling permanently, rarely albuminuria, the lym- 
phatics little if at all swollen, and strepto- or staphylococci but no diph- 
theritic bacilli. Scarlatina is excluded by the history of the attack and 
non-prevalence. Prognosis is good. Necrotic cases are graver. 

The predisposition to quinsy may be lessened by cold applications 
to the neck, salt rubbing, general cold baths, regulating the digestive 
conditions and excluding autotoxemias, but particularly by keeping 
at hand a germicidal preparation for instant application whenever any 
tonsillar irritation shows that a brood of microbes has begun opera- 
tions there. The chlorine mixture described in the chapter on diph- 
theria answers this purpose admirably — a teaspoonful taken undiluted, 
repeated every two hours as needed, promptly quells the commotion 
in its incipiency, and as the attacks are prevented the predisposition 
to them subsides. 



458 CHRONIC TONSILLITIS. 

Clear the bowels at once and decidedly, by calomel followed by 
salines, and without waiting for this begin giving calx sulphurata, gr. 
1-6 every quarter-hour till saturation, and sustain this till the attack 
is jugulated. This will be materially aided by the use of the chlorine 
as abeve. The same good result has been attained by administering 
nuclein solution, five drops on the tongue every hour. Other useful 
but less efficacious remedies are guaiac lozenges, constantly sucked; 
sodium salicylate, gr. 5 every two hours, nitrate of potassium in the form 
of 'quinsy balls', and a 10 to 20-grain dose of quinine. A full hypoder- 
mic dose of pilocarpine, gr. J, has also succeeded. Relief may be had 
from small pellets of ice sucked, or ice cream; or cold to the outside of 
the neck. 

The suffering may require hypodermics of morphine and atropine, 
which are not very effective, as is usual when there is imprisoned pus. 
Fever demands aconitine enough to hold the circulation near normal 
equilibrium, and this is thought to exert specific powers here. Bos- 
worth's advocacy of tincture of the choride of iron as a specific when 
given early is simply so much more testimony to the efficacy of chlorine. 
Cocaine solutions locally give some little momentary relief; scarifications 
much more. The early evacuation of pus is at once followed by sub- 
sidence of pain and fever. Guard all but the end of the bistoury by 
wrapping with adhesive, and cut out toward the center of the throat. 
Dyspnea may be so extreme as to necessitate tracheotomy, 

CHRONIC TONSILLITIS 

Repeated attacks of acute inflammation result in hyperplasia of the 
glandular and connective elements, the latter gradually destroying the 
former and contracting the gland — resulting in Pynchon's small, sub- 
merged tonsil. Caseous masses may occupy the follicles. Nasopharyn- 
geal catarrh, adenoids and implication of the eustachian tube and 
impairment of hearing may attend. Predisposing causes are the scrofu- 
lous or syphilitic diathesis, boys between 5 and 15 being most frequent 
victims, living in bad hygienic influences. Excitants are those of the 
acute form, and infectious maladies. The symptoms may be a liability 
to acute attacks, hawking of mucus, obstructed nasal passages leading 
to mouth breathing, sleep being disturbed by dyspnea, or nightmare from 
imperfect oxygenation. Swallowing may be difficult, in the subacute 
exacerbations. Wheezing and croupy cough are common. Asthma 
may occur. Tinnitus is frequent. Taste and smell are impaired. 
Plugs in the crypts render the breath offensive. The expression is 



CHRONIC TONSILLITIS 459 

stupid, thought and speech slow. Stammering is not rare. Mental 
development may be retarded and the child does not keep up with his 
comrades in school. Chicken-breast sometimes develops, the ribs 
separate widely in front and approximate posteriorly. The upper chest 
narrow, the shoulders prominent. The first heart sound is weak. The 
lower lateral thorax is retracted in inspiration. Puberty may be retarded, 
anemia is marked, headache follows attempts at forced study, palpita- 
tion, habit-chorea, enuresis, are associated with capriciousness and a 
sullen disposition. Aprosexia, inability to concentrate the mind on 
any subject, is marked. The diagnosis is made by inspection. Adenoids 
may be detected by passing the finger into the pharyngeal vault. Nasal 
obstruction is to be excluded if it does not coexist. Thumb-sucking 
deforms the jaw, the central incisors protruding. In retropharyngeal 
abscess the swelling is acuter and in the median line, pushing the palate 
forward. 

The tonsils should be removed in whole, not sliced down. As ordinarily 
employed the tonsillitome simply removes the superficial layers of the gland, 
while the diseased portion of the tonsil is hardly touched. Pynchon, 
who is probably the foremost living authority on the subject, prefers the 
galvanocautery. Sometimes we find patients who absolutely refuse 
any operative procedure, and very rarely will carry out more tedious 
methods. A girl 8 years of age vehemently objected to being cut or 
burned. Her nurse, a very intelligent and capable French girl, offered 
to carry out our plan and the child agreed to it. The nurse applied 
pure water free glycerin to the tonsils at least twenty times each day, 
securing each time a slight abstraction of water therefrom, the effect 
being made sufficient for therapeutic purposes by the numerous repeti- 
tions. Within a month the tonsils were reduced to their normal size. 
If any man ever cured such cases by the application of absorbents locally 
or internally, he has had better success than the writer, with the above 
exception. And yet it is a question whether the wholesale extirpation of 
this organ, which presumably has some purpose in the human economy, 
is entirely justified. Is it not possible that early in the disease, before 
marked degenerative changes have taken place, much might be 
done by cleaning out the crypts and applying antiseptics and tissue 
stimulants, with the internal administration of alteratives and cellular 
stimulants, such as calcium suphide, calcidin and nuclein ? 

Internal treatment consists in meeting such indications as each case 
may present. Acute exacerbations are to be treated by suitable local 
and general expedients similar to those described in the article upon 
Acute Tonsillitis. 



4 6o ACUTE PHARYNGITIS. 

V. DISEASES OF THE PHARYNX 

ACUTE PHARYNGITIS 

The predisposing causes of catarrh of the pharynx are, the scrof- 
ulous or other diathesis, autotoxemia or uricacidemia, and the habit 
established by repeated previous attacks, excitements, irritating food 
or drinks, exposure to cold and wet, and the presence of any stray swarm 
of microorganisms that may settle on this spot. Catarrh may extend 
from the nose. In influenza and other infections it is epidemic. Many 
microorganisms have been found here. 

The first symptom is itching, followed by burning and dryness, 
stiffness and dysphagia as swelling appears; dry cough with hawking, 
often the ear or larynx participating. The membrane is red, lilac or 
purple. Spots or patches of exudate or secretion may appear. Herpetic 
vesicles may be present. The onset is rarely heralded by chilliness, 
headache, fever, rapid pulse, dry skin and anorexia. Within a week the 
attack runs its course and subsides, leaving some infiltration and soreness. 

The diagnosis is made by inspection. 

This malady offers a ready opportunity for demonstrating the truth 
of the proposition that in the beginning of an acute hyperemia the 
attack may be aborted by a powerful contractor of the vessels. Many 
times we have quelled the incipient riot by a few doses of the chlorine 
mixture described in the chapter on diphtheria, or by painting the focus 
of beginning inflammation with tincture of iodine or of benzoin, or 
glycerin of tannic acid, or chromic acid solution; in fact any efficient 
astringent. Recognizing the fact that such attacks often indicate tox- 
emia and this the weakest point at which the general poisoning may 
be manifested, a brisk cathartic and abstinence from rich food for a day 
are indicated. Every time such an attack is permitted to run its 
course the predisposition to subsequent ones increases, and every time 
it is jugulated this ■ predisposition is weakened. The domestic remedy 
of gargling with capsicum acts by stimulating the local tissues which 
by increased vitality are aroused to throw off the disease. Sanguinarine 
acts in this way — gr. 1-67 every quarter hour till faint nausea indicates 
the beginning of toxic action. Many other local remedies have been 
used with success, the principle action being as above stated. Inhala- 
tions of steam relieve established inflammation, as do sprays of campho- 
menthol, or lozenges of guaiac. The capillary engorgement is also to 
be quelled by the internal use of aconitine or veratrine. A hot mustard 
footbath on going to bed is a useful derivative. 



CHRONIC PHARYNGITIS 461 

Membranous pharyngitis occurs in debilitates cachectic persons on 
exposure to cold or impure air, and during epidemics of infectious 
fevers. The symptoms are those of a severe catarrh, with a thin, yellow- 
ish false membrane appearing in patches, with vesicles, easily detached 
and leaving erosions but not ulcers. The treatment above detailed 
amply suffices. 

CHRONIC PHARYNGITIS 

We see nasopharyngeal catarrh, a dry form, and a follicular variety. 
The membrane may be red, thick and viscid, or pale, thin and dry. The 
glands may project as red nodules, the lymph cells hyperplastic and 
secretions retained. These maladies are common in men of sedentary 
habits, hard brain workers, public speakers who frequent rooms laden 
with foul air and tobacco smoke or chemical vapors, or who strain the 
voice. Digestive difficulties, autotoxemia and nasal maladies aid the 
causation. 

The ordinary symptoms are slight, dryness or irritation appearing 
when the voice is used, and subacute attacks following exposure of any 
sort or increase of autotoxemia. A full meal — Thanksgiving dinner — 
is sure to be followed by an attack. The patient is often unconscious 
of a habitual cough or hawking, getting up a little adhesive mucus, 
especially on rising. The membrane is seamed with scars, interspersed 
wnh nodulations and shallow erosions or ulcers. Secretions may be 
present. Taste, smell and hearing become weakened. The uvula 
may be lengthened. Headaches and vertigo are common. The veins 
may be enlarged and tortuous. The pharyngeal tonsil may be enlarged. 
The general symptoms are those of the sedentary, meat-eating brain- 
worker with autotoxemia. The diagnosis should exclude syphilis and 
tubercle. Complete cure should not be promised. 

The treatment of this group of conditions has required whole books 
to describe, and the reader is referred to the works of specialists for 
minute particulars. The indurations may be touched with tincture 
of iodine every other day; thymol iodide one part in 16 of pure fluid 
petrolatum sprayed over the membrane every night and morning, after 
removing the secretions by salt gargles or mild alkaline lotions; and the 
alimentary canal kept clear and aseptic in the usual manner. This will 
secure immediate and decided improvement. If the patient can be 
induced to properly regulate his diet and take enough exercise, and 
keep doing this, he will recover insofar as recovery is possible — among 
the miracles wrought by the newer therapy the rebuilding of atrophied 
tissues is not numbered. 



462 ESOPHAGITIS. 

Lozenges of gum, glycerin or elm relieve dryness by exciting saliva, 
and keep the membrane moist. Potassium bichromate is credited 
with valuable properties in chronic infiltrations, and in quelling sub- 
acute exacerbations. Painting the affected membrane with a 2 per cent 
solution of brucine five minutes before going on the stage aids public 
speakers remarkably, freeing them from irritation, clearing and 
strengthening the voice. A good lozenge is a grain tablet of arbutin, 
allowed to dissolve as slowly as possible in the mouth. This may be 
repeated /. i. d., for months with benefit. 

Phlegmonous inflammation and abscess sometimes occur in the 
throat, the symptoms being those of a boil in any locality. The onset 
is sudden and severe. Respiration may be impeded. The treatment 
consists in quickly saturating the patient with calx sulphurata, a grain 
every half hour, with five drops of nuclein solution dropped on the tongue 
every hour. Clear the bowels with calomel and saline aided by exos- 
motic enemas. If pus forms evacuate it at the earliest moment. 

Retropharyngeal abscess is most frequently seen in children under 
two years of age, and with caries of the cervical spine, infectious fevers, 
and rarely from perforation with a fishbone, pin, or other foreign body. 
There is pain on swallowing, impeded respiration, cough, alteration of 
voice, obstruction of the esophagus and stiffness of the neck. In infants 
the latter, with some fever, restlessness, insomnia and other general 
symptoms, are notable. The pharynx may be seen to project forward. 
The course is brief except when the vertebra is carious. Death may 
be caused by asphyxia. In adults the diagnosis should be made from 
aneurism. The treatment consists of quick saturation with calx sul- 
phurata and nuclein, clearing the bowels, and evacuating pus as soon 
as its presence is detected. Caries demands the supporting treatment 
also. 

VI. DISEASES OF THE ESOPHAGUS 

ESOPHAGITIS 

Acute catarrh of the esophagus results in the production of spongi- 
ness and desqamation of the mucosa instead of mucous secretion. The 
glands may break down into ulcers, erosions may form, or an exudate 
appear in the lower segment. Submucous suppuration may dissect up 
the mucosa. Corrosive poisons may destroy the whole or parts of the 
tube's thickness. Fibrinous casts have been ejected by hysterics. The 
cause is generally traumatism, mechanical, thermic or chemical irrita- 



ESOPHAGEAL CARCINOMA 463 

tions, extension from the pharynx, specific infections, smallpox pustules, 
and local disease like cancer, abscess or laryngeal caries. The symp- 
toms are a dull steady pain beneath the sternum, difficulty in swallow- 
ing, regurgitation of food, and discharge of mucus, blood and pus. 
Ulceration or necrosis may follow. The diagnosis may be confirmed 
by passing an esophageal sound. 

Rectal feeding may be requisite. The treatment is conducted on 
general principles, attempts being made to abort the attack when feas- 
ible, by calx sulphurata and nuclein. 

Chronic esophageal catarrhs may be due to extension, continued 
irritation, or passive congestion from cirrhosis or chronic cardiac 
disease. Nausea and eructations may be caused by mucous secretions. 
All varieties of esophageal inflammation are singularly rare. 

Esophageal ulcers may arise from catarrh or gangrene, and may 
form in bedfast persons opposite the cricoid cartilage. Pus may be 
discharged into the tube or the mediastinum. Stenosis may follow. 
Peptic ulcers may form here. Passage of a bougie reveals local points 
of tenderness and maybe pus and blood. The treatment is symptomatic 
and general. 

ESOPHAGEAL CARCINOMA 

This is the most frequent disease of the esophagus. It is primary, 
epithelial, beginning in the mucosa and encircling the tube, narrowing 
its lumen and often causing dilatation above the obstruction. It is usually 
in the lower third, where the left bronchus crosses. Males, over 40, 
are the most usual victims. The causes surmised are continued irrita- 
tion as in the case of drunkards, and the presence of scars here from 
peptic ulcers. 

The first symptoms are those due to beginning stenosis as the tube 
is narrowed. This steadily increases until only liquids can be swal- 
lowed, and regurgitation occurs. Pain may be marked. Food, and 
when ulceration has occurred blood, pus and cancer tissues may be 
ejected. Obstruction may temporarily subside when the mass breaks 
down. Secondary growths develop in the lungs, liver, etc. The cervi- 
cal glands may be affected. The general symptoms are some fever 
with progressive wasting and cachexia. The deprivation of food may 
cause the blood to show an excess of corpuscles to its bulk. 

The duration seldom exceeds eighteen months, much less in soft 
cancers, the patient dying of exhaustion. The larynx, trachea and 
bronchi may be invaded, the pericardium, pleura or aorta be perforated. 



464 ESOPHAGISMUS, DILATATION, STRICTURE 

The vocal cords may be paralyzed by pressure on the recurrent laryn- 
geal nerve, and gangrene of the lung is not common. The diagnosis 
is made by excluding other causes of dysphagia: aneurism, foreign 
bodies, cicatrices, mediastinal and other tumors. The relentless prog- 
ress of the case is significant. The esophageal bougie is to be employed 
with caution as harm may be easily done. 

The treatment is symptomatic and palliative. Condurangin should 
be administered, gr. 1-67 every four hours, in solution, as this has 
proved of value when brought into direct contact with cancerous growths. 
Rectal feeding is indicated. Gastrostomy prolongs life. 

Rarely the esophagus is ruptured, previous softening by autodiges- 
tion supposedly occurring. Food and air escape into the pleura, causing 
fatal inflammation and suppuration. The perforation occurs in the 
posterior wall of the lower section and is large. Violent vomiting after 
a full meal is blamed. The symptoms occur suddenly, nausea, very 
severe vomiting, great local pain, and collapse. Cervical and thoracic em- 
physema develops. Death is not long coming. No curative treatment. 

ESOPHAGISMUS, DILATATION, STRICTURE 

EsophagismilS, spasm of the muscular fibers, occurs in hysterics, 
chorea, epilepsy and hydrophobia; rarely primarily. It has been seen 
in aged hypochondriacs, pregnant women, and following primary esopha- 
geal atony and aneurism. Dysphagia occurs, with pain, emotional 
symptoms and choking. The bougie may pass the tube and be tightly 
gripped. When the spasm subsides there is no obstruction. The 
treatment is mainly psychic, and the use of the bougie is specially effec- 
tive. As the malady is frequently reflex, the source of the hyperesthesia 
is to be sought. 

Dilatation occurs above a stricture, after preliminary narrowing from 
hypertrophy. It may follow esophagismus, or be congenital. The 
symptom is continual dysphagia, at one point, with regurgitation of 
food not acidulated unless vomiting attends. The sound detects the 
dilatation and the stricture below. Feeding may be maintained by the 
use of Symond's tube, and by the rectum or vagina, the latter more 
successfully. Contraction may ensue if the stricture is opened and the 
tube kept empty, and berberine may be given, one to five grains a day 
for six weeks, to favor this. 

Partial dilatation may cause a diverticulum, and this may be congeni- 
tal. The wall is weak at one point and a hernia forms. Food lodges 



ESOPHAGISMUS, DILATATION, STRICTURE 465 

in it and enlarges the sac by iis weight, and by decomposing sets up 
disease of the walls. It is most usual on the posterior wall below the 
pharynx. It may measure four inches in diameter. It is most usual 
in elderly men, following local injurv or disease. Small funnel-shaped 
traction diverticula also are found in children rarely, following suppura- 
tion of the bronchial glands. They cause few symptoms if any — except 
what are due to the entrance of food. The larger forms are recognized 
when they cause pressure symptoms, dysphagia, bad breath, nausea 
and vomiting with associated strangling, and the inanition of denutri- 
tion. The sac full of food may be palpated or percussed. Dyspnea, 
coughing, etc., are caused by nerve pressures. 

The sac enlarges when food is taken and subsides when it is ejected. 
This may be effected by compression with the fingers. Diagnosis with 
the sound is rather difficult. The x-ray affords a better means. Cura- 
tive treatment is surgical. Feeding should be by the stomach tube 
exclusively, as food should never be allowed to enter the sac. 

Esophageal Stricture occurs from epithelioma, polypi, syphilis, tuber- 
cle, corrosives, typhoid or peptic ulcers, and congenitally. The symp- 
tom is very slowly increasing dysphagia from obstruction. A sense of 
weight and pressure follows eating, and there is apt to be pain also. At 
first fluids are taken readily but in time they also are arrested. Muscu- 
lar atony adds to the difficulty. Tissue may be destroyed by corrosives, 
and spasm may also occur. In cancer the obstruction is wholly mechan- 
ical Dilatation forms above the stricture. Food arrested is ejected 
several hours after meals, and is alkaline. Debility and emaciation 
progress from lack of nourishment. Diagnosis is made by use of grad- 
uated sounds. First spray with cocaine to prevent spasm and vomit- 
ing; put the patient on a low seat, his head supported by an assistant 
behind him, and slightly held back; the operator stands in front of him, 
the left index finger passed into the mouth to locate and avoid the epi- 
glottis; the bougie is guided into the tube. It may be gripped by spasm 
at the level of the cricoid cartilage, passing with a jerk — no force is 
permissible — or be arrested, and a smaller size must be substituted. In 
locating the strictures, from the teeth to the cricoid cartilage is about 
seven inches, the left bronchus eleven, the diaphragm fifteen. The diag- 
nosis as to the nature of the obstruction is to be made. External com- 
pression causes moderate obstruction; aneurisms may communicate 
rhythmic movement to the sound pressed against the obstruction, and 
will afford other pressure symptoms. Spasm and paralysis occur in 
hysterics and rarely afford other than intermittent obstruction. Can- 
cers occur in elderly men and simple forms have their peculiar history. 



466 STOMACH TROUBLES 

Dilate the stricture by the gradual introduction of graduated sounds, 
the softer being safer. This should be repeated daily and the patient 
should be taught to do it himself. This applies specially to cases follow- 
ing corrosion or ulcers. Feeding should be through a stomach tube if 
it can be introduced, or by rectum and vagina. Surgical intervention 
may be required. 

VII. DISEASES OF THE STOMACH 

STOMACH TROUBLES-GENERAL CONSIDERATIONS 

There are few troubles to which human flesh is heir more common 
than those which affect the alimentary tract; yet there are few with which 
the general practician is, as a rule, so unfamiliar. This is a strange 
condition of things, for aside from the "revenue" to be derived from the 
treatment of ailments of this class it has become almost axiomatic that 
a large proportion of the diseases of other organs, and especially those 
to which we give for convenience, the name of "diseases of metabolism," 
are directly or indirectly due to dietetic and consequently digestive faults. 
A thorough knowledge of digestive diseases may be the key to many 
a vexing problem. 

The cut and dried favorite prescription of something "good for 
dyspepsia" is the rule, I fear with most physicians; some know of "dys- 
pepsia" only; while many divide their cases into two classes — gastritis 
and nervous dyspepsia — but with no very clear conception of the thera- 
peutic indications which even such a simple classification might point 
out. Usually the patients all get a mixture of nux, pepsin and some 
aromatic; though once in awhile hydrochloric acid is prescribed, and 
not infrequently the ancient prescription of an alkali before meals under 
the long-since-dead hypothesis that it will stimulate a flow of the acid 
gastric juice. 

I believe that this failure to grasp the essential principles in the treat- 
ment of stomach diseases is due to the apparent complexity of the symp- 
toms described in text-books, and also to the fact that in practice these 
symptoms, even of widely varying conditions, on their surface present 
a confusing similarity. The physician depends for his diagnosis upon 
what the patient tells him, and in few conditions is this source of infor- 
mation less trustworthy. Every doctor should know how to elicit the 
objective signs of stomach disease — but he doesn't. The examination 
of the stomach is fully as easy as that of the chest; yet what doctor would 
make a diagnosis of pneumonia or pleurisy after mere interrogation of 



STOMACH TROUBLES 467 

the patient. How few there are who take the trouble to expose the ab- 
domen, and make necessary tests to get at the bottom of the trouble 
when the stomach is at fault. 

No man should think of treating diseases of the stomach without 
having some logical conception of the condition of things he is trying to 
remedy. The symptoms of chronic gastritis and hyperchlorhydria may 
seem to be very much alike; yet the treatment which would be indicated 
for one would be anything but beneficial to the other. Diagnosis, there- 
fore is essential, and correct diagnosis cannot be made without the tools. 
The laboratory equipment may seem formidable but after all it is simple 
enough, provided one sticks to essentials and does not try to do too 
much. Given familiarity with the use of the stomach tube and the mas- 
tery of two or three simple tests and the general man will do very well 
in the vast majority of his cases. Why the siphon tube should be such 
a bete noir to so many is hard to understand. It really is not much more 
difficult to use than it is to give an enema. Personally I would rather 
introduce the tube into the stomach than to attempt the high rectal irri- 
gation. 

Called to attend a case of stomach trouble the physician should first, 
attempt to answer the following questions: 

1. Might the conditions be caused by any trouble external to the 
stomach, and if so what? 

2. Is the stomach normal as to size and location? 

3. Is there food stagnation — in other words, does the stomach empty 
itself with reasonable promptitude? 

4. Are the secretions normal or abnormal? 

5. Are there evidences of inflammatory change or other morbid 
condition of the mucosa? 

1. Of the exterior conditions causing symptoms of stomach disease 
the most common are those which interfere with the circulation. Such 
are heart disease with failing compensation, disease of the liver, espe- 
cially cirrhosis, disease of the lungs, etc. These all cause passive con- 
gestion of the mucosa. Severe anemias interfere seriously with digestion; 
and on the other hand in many cases they are produced by digestive 
disease. Morning vomiting should suggest pregnancy. Sudden attacks 
of vomting may mean locomotor ataxia. Nausea accompanied with 
severe blinding headaches should always suggest an examination of the 
urine — perhaps they are due to uremic poisoning. Occasionally vom- 
iting may usher in the acute diseases such as the exanthemata, indeed it 
is often the evidence of a severe autotoxemia. Recurring attacks of 
severe pain in the stomach may be due to biliary colic. An examination 



468 STOMACH TROUBLES 

of other organs, especially heart, lungs, liver, an examination of the 
urine and a careful testing of the reflexes should be made in every sus- 
picious case. 

2. The stomach may be dilated (gastrectasis) or prolapsed (gas- 
troptosis). Dilatation of the stomach is caused either by obstruction at 
the pyloric end or by weakening of the gastric muscle. The obstruction 
may be either organic or spasmodic; the former is caused by ulcer or other 
acute inflammatory conditions at or near the valve or the presence or 
pressure of some growth; more rarely by constricting hands. Spasmodic 
obstruction is usually due to an irritable condition of the mucosa, usually 
the result of highly acid secretion. Weakening and thinning of the gas- 
tric muscles may follow any severe debilitating condition, in all prob- 
ability, but most frequently is a sequel of chronic gastric catarrh. 

The simplest way to demonstrate dilatation is by giving a seidlitz 
powder, the blue and white papers being administered separately. Gas 
is generated in the stomach which is ballooned out so that it is easily 
outlined by percussion and auscultation. Take care that the colon is 
not so filled with gas as to confuse your work. Also, if you are suspi- 
cious of erosion from ulcer or cancer, avoid distension of the stomach. 
To determine the motility of the stom ch give the patient a half a glass 
of water; then while he leans slightly forward, by careful percussion out- 
line the lower border and mark the point on the abdomen with a colored 
crayon; then give more water and notice how much the viscus descends, 
marking again, then still more as there may be need. Gastroptosis is 
usually part of a general process — descent of all the abdominal viscera 
or at least a good share of them; this general abdominal prolapse is called 
splanchnoptosis. Have your patient stand up with the abdomen ex- 
posed to the pubis; a pronounced case of splanchnoptosis, when observed 
from the side, shows sagging and protrusion of the lower abdomen and 
a depression in the epigastrium, or just beneath the xiphoid. Glenard's 
belt sign is useful. From behind the patient grasp the abdomen gently 
with both hands and "raise up" on it; this gives relief in gastroptos s. 

3. Food stagnation means defective motility, usually associated 
with deficient HC1; however, even when HC1 is scanty if the stomach 
empties itself promptly there may be no indigestion, since the intestine 
may take up the work in a compensatory way. As a result there 
will be no stagnation and consequent symptoms of decomposition, 
even though the secretion may be scanty. Determine the size 
of the stomach as above. The length of digestion is easily ascer- 
tained by withdrawing the contents of the stomach at varying periods 
after the test meal. Use as described below. The stagnation and de- 



STOMACH TROUBLES 469 

composition of food should never be allowed to go unrecognized for it 
demoralizes the whole digestive tract and causes many distressing symp- 
toms. 

4. While the revelations of the laboratory are by no means infal- 
lible, they throw more light upon the condition of the stomach than 
anything else. Of first importance is to learn the amount of* HC1 
secreted. The normal percentage after a test meal is, in Americans, 
from 0.15 to 0.2 per cent. In Asiatics and others living habitually on a 
vegetarian diet the percentage is normally lower. An increase in the 
secretion of HC1 means an irritable condition of the stomach; a decrease 
of HC1 a depressed condition, and this deficient secretion is present 
in practically all chronic inflammations. 

An increased percentage of HC1 usually means either hyperchlor- 
hydria or ulcer. When the acid is diminished or absent the trouble may be 
gastritis, cancer, or any one of a variety of neuroses. 

This brings us to the use of the stomach tube. This simple instru- 
ment is simply an "overgrown" soft rubber catheter, 30 inches in length. 
It may have a pump bulb or not, as preferred. The physician should 
have several tubes of different sizes. They are not expensive. Usually a 
moderately large one is introduced more easily than a small one. Scru- 
pulous cleanliness is imperative. After use the tube should be carefully 
washed and a hot solution of soda and water allowed to run through 
it until it is clean inside as well as outside. It should then be placed 
in a wide mouthed jar rilled with glycerinized water made slightly anti- 
septic with carbolic acid. Rinse again before using. To introduce 
the tube direct the patient to lean slightly forward with the mouth open. 
The tube should be held in the left hand and introduced with the right, 
the end being held like a pen between the thumb and two first fingers. 
Introduce it gently until it touches the posterior pharynx, then tell the 
patient to swallow, meanwhile pushing it onward very gently. Use no 
force; it will go forward easily enough. On the first introduction the 
patient will gag and endeavor to reject the tube, but this soon passes. 
Use tact; reassure him and do not be in a hurry. After the first intro- 
duction there is little trouble. 

Many test meals are given in the books, but the Ewald-Boas meal 
meets all usual needs for the general practician. It consists simply of 
a slice or two of dry bread or a roll eaten with a glass of water or a cup 
of weak tea, without sugar, cream or butter. It must be taken on an 
empty stomach and the product of digestion remaining should be with- 
drawn with the tube in an hour. If digestion has been fairly good all 
that will remain is a few ounces of straw colored liquid, mixed slightly 



470 STOMACH TROUBLES 

with mucus; if digestion is feeble, broken down and partially digested 
food fragments will be found with more or less mucus, epithelial debris 
and possibly blood, while the microscope may show bacteria and fungi 
of various kinds. 

There are many chemical tests in use, but the following three will 
answer the purposes in general practice: (i) the dimethylamidoazo- 
benzol test for HC1; (2) the phenolphthalein test for total acidity; and 
(3) the ferric chloride test for lactic acid. 

In making quantitative tests it is necessary to use what is called an 
indicator', this is a solution of some substance which changes in color 
when the reaction changes from acid to alkaline, or the reverse. Also 
we must have a carefully measured percentage solution of an alkali which 
serves as a "measuring stick"; for this purpose what is called a "decinor- 
mal" solution of NaOH is usually employed. A normal solution is one 
which contains in every liter as many grams of the substance as its 
molecular weight. For instance, the molecular weight of NaOH is 40; 
hence a normal solution of NaOH would contain 40 grams to the liter; 
but as these quantities are often inappropriate for making solutions it 
is the custom to use decinormal solutions, one tenth of this strength in 
the case of the NaOH or 4 grains to the liter. 

Now for our test for free HC1: Having carefully filtered the fluid 
we have withdrawn from the stomach we add to a carefully measured 
quantity (10 Cc) two to three drops of our indicator, dimethylamidoazo- 
benzol in 1-2 percent alcoholic solution. This turns the gastric filtrate 
a vivid red. From a graduated burette we now add drop by drop, 
shaking or stirring carefully from time to time, the decinormal NaOH 
solution until the red color fades entirely away. This fading of color 
means that the acid is neutralized. The amount of the NaOH used 
gives us a basis for computation. For instance, if 6 Cc of the NaOH 
solution are required to neutralize 10 Cc of the gastric filtrate it would 
take 60 parts to neutralize 100 Cc. Or the acidity may be stated at 60. 
If it is wished to state this in percentage the 60 is multiplied by .00365 
the quantity of HC1 in a gram of decinormal HC1 solution. (This 
factor may be easily remembered as it is the same as the number of days 
in a year.) Given a free acidity of 60, the percentage acidity would 
be 0.219. 

But HC1 does not exist free in the stomach alone; some of it has 
entered into combination with various bases and formed chlorides, 
while other portions have combined with albumen to form peptones, 
etc. In addition there may be other acids. To get some idea of the 
total work of the stomach therefore it is well to determine the total acidity. 



STOMACH TROUBLES 471 

For this our indicator is the phenolphthalein. This is used exactly 
as the dimethylamidoazobenzol is used, but instead of reddening the 
acid solution it causes no change in color until the NaOH is added. 
This turns it red. When enough of the alkali is added to cause a per- 
manent and uniform red color after shaking, the acidity is neutralized and 
the quantity and percentage may be computed exactly as already 
described. To determine just when the reaction is completed requires 
a little experience, for the change of color is not sudden but gradual. It 
is the custom to state free HC1 acidity in percentage and total acidity 
in terms of the neutralizing agent. Thus in a given case we may say 
that the HC1 was found in a percentage of 0.18, and the total acidity 
(all the acids free and combined) was 70. 

When cancer of the stomach is suspected the filtrate should be 
examined for lactic acid which is found in excess in this condition. The 
test meal here is oatmeal gruel without sugar or milk. (This meal is used 
because wheat bread and most foods contain milk sugar). 

The solution used consists of a strong ferric chloride solution in 10 
Cc of a 1 per cent solution of carbolic acid. WTien this is added to 
the gastric filtrate a violet-color liquid is formed which becomes 
lemon-yellow in the presence of lactic acid. To avoid complications 
from the presence of other substances the lactic acid should be extracted 
with ether, then evaporated and a watery solution made for test purposes. 

5. Inflammatory changes of the mucosa, in other words " catarrh 
of the stomach," are suggested by decided and permanent reduction 
of HC1, as determined above. This suspicion may be verified by a 
macroscopic and microscopic examination of the gastric content. The 
presence of mucus in considerable quantity practically always means 
gastritis. It is only absent in gastritis when the disease has advanced 
to the point of destroying the mucous lining. Also, a microscopic 
examination will show more or less degenerated and broken down 
epithelial cells and usually bacteria, yeast cells, sarcinae, etc. Blood 
is not infrequent and usually means either ulcer or cancer. 

Before entering into an extensive investigation of the signs of disease 
the physician has of course interrogated his patient concerning his 
symptoms. These often give valuable if not infallible information. 
The patient should elicit the following facts: 

1. The family history, especially as regards stomach disease and 
"nervousness." 

2. The duration of the trouble. 

3. The coexistence of any intercurrent disease or other trouble- 
some symptoms not referred to the stomach. 



472 STOMACH TROUBLES 

4 Is there pain; if so does it come immediately after meals or at 
some distance after eating ? Is it relieved or increased by taking food ? 

5. Nausea and vomiting. At what time of the day do they occur, 
how soon after meals, and what is the nature of the vomited matter? 

6. Points of localized or general tenderness, to be verified by phy- 
sical examination. 

7. Is there constipation or diarrhea? 

In many cases the diagnosis will be fairly clear after careful inter- 
rogation, and the patient may be placed upon a tentative treatment 
with reasonable hope of benefit. But .in severe cases of long standing 
it pays to be thorough. 

Having elicited all the facts possible in the mothods described how 
shall we utilize them ? By putting two and two together we can now form 
a pretty accurate estimate of the condition, even if we are not quite 
sure of the name it should go by. Let us see what is meant by the vari- 
ous symptoms-complex: 

Hydrochloric Acid Excess:— This is due in the vast majority of cases 
to one of two things: Hyperchlorhydria, the most common of causes 
of indigestion, or gastric ulcer. (Rarely "acid gastritis" may cause 
it but the dividing line between it and hyperchlorhydria is somewhat 
vague.) To differentiate: The pain in hyperchlorhydria comes 
at the height of digestion, one to three hours after eating, is relieved by 
taking food and by the use of alkalies. Gastric- ulcer pain commences 
as soon as anything is taken into the stomach and only ceases when 
the stomach is empty. The patient often has blood in the vomitus 
and occasionally in the stool. Localized tenderness in ulcer, absent 
in hyperchlorhydria. 

Hydrochloric Acid Reduced or Absent:— This is probably due to 

one of three things: Gastritis, cancer, or a neurosis of defective secre- 
tion (hypochlorhydria). To differentiate: Diffuse pain increased by 
taking food; no hemorrhage; vomiting quite common, morning vomit- 
ing in alcoholics; vomit contains mucus; no lactic acid; nutrition 
impaired but no rapid emaciation — these are observed in chronic gas- 
tritis. In cancer there is constant pain; lactic acid is present, HC1 
being often entirely absent; generally a tumor may be felt; blood, 
grumous vomit and stool; rapidly developing emaciation. Hypo- 
chlorhydria is more common in the young than the preceding; no hem- 
orrhage; percentage of HC1 is variable; vomiting not a prominent 
symptom; no mucus; general and local symptoms of neurotic type. 

Pain and Tenderness:— The severity of the pain, it should be kept 
in mind, is no safe guide as to the severity of the disease. The loudest 



STOMACH TROUBLES 473 

complaints are made by the neurotic. In ulcer the pain is sharp, acute, 
and dependent upon the presence of food; it appears as soon as it is 
taken into the stomach, while it is accentuated by the highly acid secre- 
tion; vomiting brings relief; there is associated localized tenderness, 
often a spot not larger than a silver dollar; inquire concerning blood 
in vomit and stool. In gastritis the pain is dull, more a sense of dis- 
comfort, and the tenderness is diffuse; discomfort comes on soon after 
eating and is associated with gas distention. In cancer the pain is 
more nearly constant, food may cause discomfort and vomiting, but 
is not itself the cause of the pain; grumous vomit; a tumor; tenderness 
on pressure; emaciation. In hyperchlorhydria the pain comes on one 
to three hours after eating and is relieved by taking proteid food and 
by alkalies; acid eructation (heartburn) and diffuse tenderness. 

Vomiting and Vomitus: — Remember first that vomiting may occur 
without disease of the stomach itself; witness the vomiting of pregnancy, 
the gastric crises of locomotor ataxia and the projectile vomiting of cere- 
brospinal meningitis; moreover, in gastric neuroses where the affection 
of the stomach is relatively slight the vomiting may be the most trouble- 
some symptom, resulting from an exaggerated sensitiveness of the organ. 
Vomiting in the morning before taking food is a prominent symptom 
of alcoholic gastritis (as well as of the early months of pregnancy.) In 
acute gastritis and on occasions in ulcer food is rejected as soon as it is 
taken and painful retching may follow after emptying the viscus. 
In hyperchlorhydria vomiting is not a constant symptom, and when 
it does occur is more likely to be the regurgitation of intensely acid 
fluid. In chronic gastritis the vomiting is likely to be delayed until 
fermentation and its consequent distress occurs — an hour or two; the 
vomited matter is often large in quantity and consists of undigested 
food, sour or foul smelling, frothy and mixed with mucus. 

Hemorrhage: — Blood is found in the vomitus, as a rule, only in two 
conditions: Ulcer and cancer. Rarely, in gastric catarrh the vomited 
matter may be slightly streaked with blood from capillary hemorrhage. 
If the blood is bright and considerable in quantity the presumption is 
that it is arterial. In most cases, however, it is dark and partially 
digested — therefore venous or capillary; this is particularly the case 
in cancer, where it is dark and "coffee ground" like in appearance. If 
not rejected by the stomach it may pass into the intestine and appear 
in the stool. Duodenal ulcer presents strong points of similarity to 
gastric ulcer; here the blood appears in the feces and is usually absent 
from the vomit. Blood from the lungs or throat may be swallowed 
and simulate hemorrhage from the stomach. 



474 STOMACH TROUBLES 

Condition of the Bowels: — Constipation is the rule in nearly all 
diseases of the stomach. It is especially marked in hyperchlorhydria 
the excess of acid passing into the duodenum seeming to neutralize 
the alkaline secretions of this part of the intestinal canal and interfere 
with normal activity. In chronic gastritis there is often an alternation 
of constipation and diarrhea; this is 'due to the fermentation and 
other retrograde changes of the fecal mass, which give rise to irritant 
substances which stimulate peristalsis; the feces are peculiarly foul. 
If there is associated intestinal indigestion the fecal mass will contain 
undigested food, especially fats. Examine for blood when you suspect 
solutions of continuity. . 

General Conditions: — In hyperchlorhydria the digestion is good and 
the nutrition of the patient does not suffer unless there is excessive 
vomiting preventing the taking of a sufficient quantity of food, or unless 
the patient starves himself on account of the pain following eating. 
In gastritis there is cachexia; the complexion becomes sallow and muddy 
often there is considerable anemia and the weight declines, though not 
excessively as a rule. In cancer the loss of weight is rapid and there 
is associated the peculiar waxy cast of countenance of malignant disease 
in the majority of cases. In the neuroses generally the symptoms are 
of a neurotic type, varying greatly from day to day. The exhaustion 
symptom of neurasthenia or the hysterogenic zones of hysteria are to 
be sought. 

DIET 

In all forms of stomach diseases the patient should be impressed 
with the importance of the following points: 

i. The food must be simple; the mixing of all kinds of things in 
a single meal, as in the ordinary course dinner, is a digestive danger. 

2. Frugality. Overeating is the source of most of our bodily ail- 
ments. 

3. Thorough mastication. And this means that the patient must 
take time to eat — must make a serious business of it — while aiming to 
get the utmost satisfaction out of the function. 

Of course there are other things of importance, such as the careful 
preparation of food, the avoidance of fried food, the value of fluid and 
its proper apportionment to the meals (often large quantites of water 
or other liquids are drunk while eating simply to wash the food down 
— with proper mastication this would cease to become a necessity), 
the proper adjustment of proteid, carbohydrates and fats, whether a 
milk, cereal or meat diet is to be advised, etc. All these things may be 



STOMACH TROUBLES 475 

important on occasion, but it is not wise, on general principles, to lay 
down too extensive rules. The main essential is to live a simple and 
frugal life. 

Recent studies by Pawlow, the great Russian student of the phy- 
siology of digestion, have shown the dependence of the stomach diges- 
tion upon psychic influences. We ail know how the mouth will water 
at the smell or even the suggestion of some appetizing dainty. Paw- 
low has shown there is a similar response in the stomach to these same 
influences, the sight of properly and appetizingly prepared food, as well 
as the smell or even the verbal description, exciting the flow of gastric 
juice — or as he calls it, the " appetite juice." This emphasizes espe- 
cially the importance of making meals attractive, by proper cooking, 
proper serving, and of bringing the mind upon the meal; the lunch- 
counter style of dining, in which the individual swallows his meal in 
haste (to repent at leisure) while he talks business to his elbow-neigh- 
bor, is unphysiologic and courts digestive disaster, with all the metabolic 
evils which follow in its train. 

While we have not the time here to descant upon them, attention 
should also be called to the studies of Fletcher and Chittenden which 
show that by thorough and complete mastication and insalivation the 
labor of digestion may be reduced to a minimum, while the quantity 
of food may be reduced by nearly half. According to Voit the average 
man doing ordinary work requires from 3,000 to 3,500 calories of food 
daily. (The calorie is the unit of food energy as measured in heat and 
is used by physiologists in measuring quantities of food.) These 
authors showed that it was possible to get along comfortably on half 
this if the food is chewed to the disappearing point. 

DIET FOR SPECIAL CONDITIONS 

hyperchlorhydria: — Food should be nomrritant and have large 
combining power with HC1 — in other words contain considerable 
proteid. Irritants, as spices, alcohol and hot drinks forbidden. Milk, 
stale or toasted bread, well cooked eggs, etc., meet the indication. 

Chronic Gasfritis:— The quantity of HC1 being small, the food should 
be finely divided, or otherwise in a form to utilize to the utmost the HC1 
and ferments. In some cases milk agrees best with the patient, in other 
cases finely chopped meat or raw meat that has been rubbed through 
a sieve does well; in severe cases raw -beef juice. Concentration of pro- 
teid food; carbohydrates in unfermentable form, such as simple cereals 
(toasted bread, zwieback, granose, well cooked wheat foods, etc.) Thor- 
ough mastication imperative. 



476 STOMACH TROUBLES 

Dilated Stomach: — Minimum of weight with maximum of nutritive 
qualities essential. Therefore no liquid foods. Give concentrated 
foods; frequent meals. General principles of diet as in gastritis. 

Ulcer of Stomach: — Food by rectum for a week or ten days until acute 
stage of ulcer begins to pass; then cautiously by mouth, commencing 
with milk and gradually adding cereals. 

Cancer of Stomach: — Concentrated foods, consulting patient's toler- 
ance; beef juice, chopped beef; milk, etc. 

Neuroses Of the Stomach: — Do not pay too much attention to patient's 
whims and fancies, but avoid, of course, any food unsuited to the gas- 
tric chemistry. If HC1 is increased, diet as for hyperchlorhydria ; if 
HC1 diminished, as for chronic gastritis, but make diet generous and 
give an abundance of fats, as cream, olive oil, and fat meats, according 
to tolerance. Meat, eggs and milk nearly always indicated. If these 
patients can be made to put on flesh not only the gastric trouble but 
the entire neurotic condition is improved. 

MEDICINAL TREATMENT 

Attention to the condition of the bowels is fundamental, since there 
is either constipation or diarrhea in practically every case — constipa- 
tion being the rule. Owing to the stomach trouble a properly laxative 
diet is often impracticable. In hyperchlorhydria alkalies are indicated 
and the laxative may be combined with it; for instance, magnesia is 
an excellent laxative. With it may be combined a little rhubarb, or 
better still juglandin to generally add tone to the whole alimentary canal. 
The following is suggested: 

Sodii bicarb dr. 1-2 

Magnesii carb dr. 1-2 

Juglandin ...... .gr. 1-6 

Cerii oxalat grs. 5 

Atropini sulph . gr. 1-500 

M. Sig. One half to one dram at a dose in water. . 
The cerium oxalate serves to quiet the stomach prone to irritability 
and the atropine checks excessive secretion. This formula is also of 
value in the vomiting of pregnancy. By the addition of a little tartaric 
acid (taking care not to add enough to neutralize the alkali) it may be 
given in effervescent combination. After the bowels are brought into 
proper condition they should be regulated by the use of the anti consti- 
pation pill (Waugh). 

In chronic gastric catarrh the first thing is to unload entirely the 
intestinal tract by the use of small repeated doses of calomel; stimula- 



STOMACH TROUBLES 477 

tion of the hepatic areas with iridin or podophyllin also may be indicated, 
for in this condition of things a large amount of work is thrown upon 
the liver and it is essential that it should functionate properly. In gastric 
catarrh the morning dose of saline is indicated; here we need the drain- 
age. These patients nearly always benefit by a residence at the "spas" 
— simply because they are cleaned out thoroughly and are kept cleaned 
out. 

In the neuroses the bowels should be regulated as far as possible by 
exercise and diet, but a preliminary cleaning out and the temporary use 
of the anticonstipation formula will almost invariably do good. 

As we have already said alkalies are the indicated remedies in hyper- 
chlorhydria; this holds good also of acid gastritis (which however is not 
very common). The ordinary domestic remedy, and an effective one, 
it is the teaspoonful of soda in half glass of water. Better is a formula 
such as we have already described, which has the advantage of at the 
same time acting as a sedative, laxative and arrester of secretion. 

Intestinal antiseptics have a wide field of usefulness in stomach troub- 
les. They are not indicated in hyperchlorhydria, for here the digestion 
is good and there should be no fermentation or putrescence of food. 
Nor are they indicated in ulcer — where the indication is for rest prim- 
arily, and secondarily for such healing agents as bismuth subnitrate and 
nitrate or oxide of silver. If the stomach is very irritable they are not 
well tolerated and may be replaced by bismuth. In all forms of gastritis, 
however, there is a tendency to the breaking down of food in the intesti- 
nal canal and as a consequence the body becomes loaded with toxins. 
The sulphocarbolates, given well after the close of digestion, are indicated 
here. If there is much gas formation this may sometimes be arrested by 
giving the sulphocarbolates with the food. In cancer they are also of 
great value for similar reasons. 

Tonics and reconstructives are indicated in practically all stomach 
diseases in which there is impairment of nutrition. The arsenates of 
iron, quinine and strychnine will be found especially valuable. Quinine 
or strychnine arsenate alone may be sufficient to restore the needed tone, 
but there is a tendency to anemia in nearly all stomach troubles and in 
this case the addition of the iron salt is especially desirable. As a cell 
stimulant there is nothing superior to nuclein. In severe cases with 
marked debility this should be given hypodermically. 

Hydrochloric acid should be administered only when the gastric 
secretion is scanty or absent. It is therefore indicated mainly in chronic 
gastritis — never, never, in hyperchlorhydria and ulcer. The dosage 
is a matter of difference of opinion. Some think that a small quantity 



478 STOMACH TROUBLES 

acts as a stimulant to increased secretion; others advise 20, 40, or 60 
minims of the dilute acid. Always give it well diluted and let it be taken 
through a glass tube. 

Pepsin is now rarely given in stomach troubles. It is known that 
in the presence of any secretion of HC1 and, sometimes in its entire 
absence, there is enough pepsinogen to do the work of the stomach. Add 
HC1 and the pepsinogen is converted into pepsin. When it is entirely 
absent, along with HC1, it is now the custom to treat the stomach as if 
it were a part of the alkaline intestinal canal, administering pancreatin 
and soda, which do practically the same work as HC1 and pepsin. 
But do not give the pancreatin and alkali when there is acid in the stom- 
ach; it will be inert. 

The vegetable digestant, papayotin, including the proprietaries, caroid 
and papoid, and possibly pineapple juice, certainly have a large field of 
usefulness in stomach diseases. The fact that they are active in any 
medium, acid or alkaline, makes them often of use in feeble digestion from 
any cause. But it certainly is not the part of wisdom to give them when 
HC1 is present — simply because they are not needed. 

Tonic bitters are an essential part of the treatment with many phy- 
sicians, but they are no longer used as much as they were. In cases of 
feeble secretion from some gastric neurosis (hypochlorhydria) quassin, 
preferably given in solution before eating, undoubtedly increases the flow 
of gastric juice. Other bitters have a similar action and carminatives 
such as piperin, capsicin, etc., may be resorted to in similar conditions 
with benefit. But in the gastric catarrhs there is a question as to the 
advisability of resorting to artificial irritants and stimulants; the stomach 
is already suffering from prolonged overwork and to stimulate it to greater 
effort may be irrational. 

Gastric sedatives may be required in nausea or vomiting. Bismuth 
subnitrate is one of the best, It should be given on an empty stomach 
and Fleiner introduced it through the tube, withdrawing water and leav- 
ing it in contact with the stomach walls. It is usually used in too small 
doses. Cerium oxalate is another excellent gastric sedative. In acute 
cases minute doses of calomel given at frequent intervals do the work. It 
may be given with small doses of ipecac (or emetine). Carbolic acid, 
1-2 gtt. given in peppermint water, is often effective, or creasote in the 
Same dose. In severe cases, morphine hypodermically. Great relief 
is often obtained from the external use of hot compresses or the hot water 
bag. (In feeble digestion it is a good plan to lie quietly on the back 
for an hour after eating with the hot water bag on the epigastrium.) A 
hot mustard draft on the epigastrium often checks vomiting. 



GASTROPTOSIS. 479 

The stomach tube is a therapeutic resource of the utmost value, but 
its field of application is rather limited. It should be used in all severe 
cases of chronic gastritis, where there are no contraindications, such as 
severe heart disease, aortic aneurism or phthisis. It is not indicated 
in hyperchlorhydria and is postively contraindicated in cancer and ulcer, 
in which its use would be dangerous. The purpose of the tube is to 
remove from the inflamed mucosa, all mucus, food fragments, germs 
and other irritants, so as to give the mucous surface a good rest. It 
should rarely be used more than once daily. An alkaline or saline solution 
is usually used for its cleansing value, but medicinal substances may be 
applied with it, directly to the diseased surface, if so desired. 

In conclusion I want to emphasize one point — the importance of 
rest in the treatment of diseases of the stomach. In acute conditions 
this is practially all that is needed. The withholding of food for a day 
or two can do no harm and is often the most certain way to bring about 
relief. In chronic cases rest is also desirable in as large a degree as is 
compatible with the maintenance of nutrition. 

GASTROPTOSIS 

This term designates a displacement of the stomach downwards. 
In many if not in nearly all cases there is a similar descent of other organs, 
the liver, colon, spleen, or kidneys. The general term is splanchnoptosis. 

Etiology: — It is more common than is usually suspected. Ein- 
horn reported that he found that 347, or 18.15 per cent, out of 19 12 cases 
examined showed some degree of splanchnoptosis. Five-sixths of these 
were women. The predisposing causes are weakness of the abdominal 
wall, muscles or suspensory ligaments, and bony deformity. In the 
majority of instances but not in all this is congenital. There may be 
arrest of cfcvelopment or a reversal to the fetal type. The infant's stom- 
ach is almost vertical and the ascending and transverse colon runs diag- 
onally upward, across the abdomen to the left. In many cases of entero- 
ptosis*this position is found. In some instances we find the floating tenth 
rib as described by Stiller. Rose emphasizes the funnel-shaped or phthis- 
ical thorax as an etiologic factor. Rickets also produces alterations 
favoring splanchnoptosis. 

Of exciting causes tight lacing is usually placed first; the corset de- 
pressing the stomach and doubling it up, approximating the cardia and 
the pylorus. Most pelvic maladies are accompanied by ptosis. Fre- 
quent pregnancies and any weakening disease that relaxes the abdominal 
connective, and also rapid loss of fat, in the obese, are often followed by 



480 GASTROPTOSIS 

this affection. Traumatisms and pelvic displacements may occasion it. 
Of Einhorn's 347 cases but two were gastric alone. Tn 212 the kid- 
neys were loose, the right kidney in 77.3 per cent of the cases. This by 
its attachment to the colon drags it and the stomach down by the gastrocolic 
ligament. Hemmeter asserts that all diseases that lead to enlargement 
and descent of the liver displace other organs as well. 

Symptoms: — There may be none; but great prolapse and long duration 
are apt to occasion distress. The digestion is disturbed, the appetite 
fails, there is a sense of fullness and dragging in the epigastrium, irregular 
colicky pains, flatulence, eructations, nausea, vomiting and constipation. 
Dilatation is common but not invariable. Patients complain of weak- 
ness on rising, fatigue on short walks, backache and weight in the lower 
abdomen. Neurasthenia is usual; anemia and debility are common. 

The patient is thin, the abdominal parietes flaccid, the lower abdomen 
protrudes and the epigastrium is depressed. Aortic pulsation is readily 
detected as the vessel is uncovered. The transverse colon may be de- 
tected as a ribbonlike band above the pubic symphysis. When the stom- 
ach contains fluid splashing may be heard on succussion. Its outlines 
may be mapped out by dilating with gas, by the flexible sound, the gyromele, 
the gastrodiaphane or the x-ray. 

Diagnosis: — is usually easy by studying the symptoms given. Ein- 
horn recommends Glenard's belt test; Standing behind the patient the phy- 
sician encircles the lower abdomen with both hands, supporting and partly 
lifting it; if the patient finds relief from this manipulation it favors the 
diagnosis of ptosis. The disease does not threaten life but complete 
cure is not common. 

Treatment: — Tight corsets, belts and heavy skirts suspended from 
the waist, are forbidden. A well fitting abdominal binder should be 
worn after confinement until the abdominal muscles have resumed their 
tonicity. This may be favored by massage, gymnastics, swimming, 
wheeling, external and intragastric faradization and galvanization. Rose 
praises rolling a five-pound cannon ball over the belly. Probably no 
other exercise affects the abdominal walls so well as sawing wood. Cold 
douches are useful, especially a strong jet of cold water directed against 
the abdomen while the patient is lying in a hot bath. Rose's plaster band- 
age is a useful support, or a well-fitting corset that is not drawn too 
tight. An elastic abdominal supporter gives comfort and prevents sag- 
ging. It the patient is thin, the diet should be so arranged as to allow 
a deposit of fat; if obese and the stomach is dilated, the greatest care 
should be exercised to prevent the organ being weighed down by a heavy 
mass of food. 



GASTRIC DILATATION OR GASTRECTASIS. 481 

Constipation must be obviated. Digestive difficulties must be care- 
fully treated. The intestinal antiseptics are frequently required, espe- 
cially zinc sulphocarbolate in doses averaging half a dram daily. Ber- 
berine specifically induces contraction of relaxed connective tissues, and 
should be given for alternate months in doses of one to five grains daily, 
divided. For anemia the preferable chalybeate is iron chloride, but any 
preparation may be employed that is otherwise indicated — iron arsenate 
for malarials, phosphate if there is need of phosphates, etc. 

GASTRIC DILATATION OR GASTRECTASIS 

Whenever there is an increase in the normal size and capacity of the 
stomach the condition is known as dilatation or gastrectasia. Mere en- 
largement of the stomach, however, is not inevitably the cause of serious 
symptoms; so long as the motor power of the viscus is retained, so that 
it is able to empty itself promptly, no trouble may result. Usually there 
is an associated stagnation of food to which the symptoms are really due. 

Etiology: — Dilatation is due to one of the following factors: (1) 
Some obstruction at the pylorus; or (2) weakening of the stomach wall. 
The pyloric obstruction may be either organic or spasmodic; in the 
former case due to cancerous growth, the pressure of tumors, the pres- 
ence of an ulcer with its resulting cicitricial contraction or peritoneal ad- 
hesions; in the latter, to excessive irritation at the pyloric orifice resulting 
in its spasmodic closure — as a result of ulcer or an excessive secretion of 
hydrochloric acid. Any stenotic condition at this orifice, whether organic 
or spasmodic, will cause dilatation of the organ. 

Perhaps less frequent as a cause is weakening of the muscular wall. 
The continued overloading of the organ by overeating, or with excessive 
quantities of liquid, may be the cause of this condition. Anything which 
interferes with the nutrition of the gastric muscles, as for instance gastric 
catarrh, will act as a predisposing cause. Gastritis when long continued, 
by predisposing to gas formation, innutrition, and myasthenia often ter- 
minates in dilatation. Conditions of lowered nutrition generally also 
favor its production. 

Symptoms: — Mainly those of food stagnation, modified by the 
condition causing the disease. If pyloric obstruction is due to cancer 
or pyloric ulcer, of course the symptoms of these diseases will be prom- 
inent and may overshadow the complicating gastric dilatation. If the stom- 
ach cannot readily empty itself fermentation processes occur, with the 
formation of gases, as for instance sulphureted hydrogen, carbon dioxide, 
hydrogen, oxygen, and marsh gas. The gaseous distention causes a sense 



482 GASTRIC DILATATION OR GASTRECTASIS 

of fullness and oppression in the epigastric region, and there are frequent 
eructations of foul smelling gas, and occasional regurgitations of sour fluid. 
The appetite is usually absent, though occasionally it is increased; the 
tongue is coated, the breath foul, the mouth and throat dry, and there is 
troublesome thirst. Vomiting is one of the most characteristic symptoms 
of well marked cases. The vomiting may occur daily or only once in two 
or three days. The quantity thrown up may be enormous. It consists 
of a frothy mixture of poorly digested food fragments in a turbid, foul, 
acid liquid. The vomiting gives temporary relief. The vomitus when 
allowed to stand separates into three layers; a lower one of food debris; 
a middle one of dirty brownish fluid and an upper one consisting of 
turbid foam. An examination of the vomitus will show undigested 
muscle fibers, starch grains, fat globules, etc; also yeast cells and 
various bacteria. 

The quantity of urine is reduced and the urea and chlorides are di- 
minished. 

The general health of the patient is more or less seriously affected. 
There is usually progressive emaciation and there may be serious blood 
deprivation. These patients become anemic, sallow and hypochondriac. 
Complications include palpitations and irregularity of the heart, asthmatic 
seizures, globus hystericus, etc. 

Upon physical examination the diagnosis is usually easily verified. 
The outlines of the stomach can be easily outlined by administering a 
Seidlitz powder, giving the white and blue papers separately, and allow- 
ing the stomach to be ballooned out by the gas which is generated. Per- 
cussion enables the physician to then outline the boundaries of the organ. 
Or, instead of the Seidlitz powder, the stomach may be dilated with air 
pumped in with a bulb syringe, or its lower border may be determined 
by giving the patient one or more glasses of water which gives a dull sound 
on percussion. Splashing of fluids may be felt on percussion and heard 
with the stethoscope, as well as the bubbling, crackling sound 
due to the evolution of gas. Tumors, or the stenotic feeling of 
pylorus when the seat of a chronic inflammation, may be detected fre- 
quently. Other aids to diagnosis are transillumination with Einhorn's 
gastrodiaphane the use of the x-ray after the walls of the stomach are 
coated with bismuth administered in large doses^Turck's gyromele or 
flexible rotating sound, and the usual chemical tests for acidity and mo- 
tility, for the latter purpose the salol test (whose value is doubtful). 

The prognosis depends upon the cause. Where the cause is a benign 
one, as muscular weakening due to overloading the stomach, gastric hyper- 
chlorhydria or eyen ulcer, the prospects for recovery are good, under 



GASTRIC DILATATION OR GASTRECTASIS 483 

proper treatment. Cancer of course removes the possibility of perma- 
nent recovery. Permanent stenotic changes in the pyloric opening may 
require surgical measures for their relief. 

Tredtment: — This must of course be adjusted to the cause of the dilata- 
tion. The physician should make a careful examination of the stomach 
contents and adapt his diet and his remedial measures accordingly. In 
many cases more can be expected from surgical procedures, those which aim 
to enlarge the pyloric opening or establish a permanent fistula between 
the stomach and the gut. 

The diet is of the utmost importance. It is essential that it should 
be concentrated, so as to have the minimum of w r eight with the maximum 
of nutrition. Fluids are generally heavy in proportion to the amount 
of real food which they contain, hence soups, gruels and even milk are 
usually contraindicated, though in some cases a milk diet proves bene- 
ficial, provided it is not given in too large quantities at a feeding. If 
there is high hydrochloric acid acidity scraped or minced raw or par- 
tially cooked lean meat is usually well borne and answers the purpose. 
The carbohydrates which are taken should be of a character not to 
undergo fermentation easily, hence sweets generally are contraindi- 
cated. In very severe cases the meals should be small, highly nutritious 
and relatively frequent, endeavoring however to give the stomach oppor- 
tunity for rest. In some cases it may be necessary to feed for a time by 
the rectum. If there is associated chronic gastritis with scanty HC1 
secretion, feed as directed for that condition, remembering the neces- 
sity, as in all these cases, of giving the maximum of nutriment with the 
minimum of weight. 

Lavage is perhaps the most useful single expedient in the treatment 
of dilatation, especially when associated with chronic gastritis. The 
purpose is to completely empty the organ,, remove all irritant substances 
from the inflamed mucosa and put it in a condition of complete rest. 
The stomach tube is easily passed, as described in the section on chronic 
gastritis; after removal of the stomach contents, the organ is washed 
out with a slightly alkaline and antiseptic solution, to remove mucus 
and check further tendency to fermentation. It is usually sufficient 
to wash out the stomach once a day, and the best time is two or three 
hours after the evening meal so that it may have time for complete 
rest during the night. Medicinal agents, as a 1 to 1000 solution of 
nitrate of silver, may be sprayed through the tube. 

In some of the milder cases the use of the tube may not be abso- 
lutely required. In these cases the best results are obtained by the use 
of antiseptics in connection with a careful diet. The sulphocarbolates, 



484 GASTRIC DILATATION OR GASTRECTASIS 

best in the form of the combined W-A Intestinal Antiseptic tablet, con- 
sisting of the sulphocarbolates of calcium, sodium and zinc, may be 
given in 5-grain doses after meals. Einhorn recommends for this pur- 
pose benzothymol, salol, bismuth and resorcin, but none of these 
remedies will be found so uniformly satisfactory as the sulphocarbolates. 
The combined salts may well be given in all cases after every meal, 
where there is the symptom of gaseous distention. By checking this 
distressing symptom one important element in the pathogenesis of the 
disease is removed. In cases attended with insufficient HC1 secretion 
this remedy should be prescribed; if' it is excessive in quantity alkalies 
are called for, as directed in the treatment of hyper chlorhydria. 

As a muscular tonifier strychnine is indicated in some of these cases; 
small doses, gr. 1-67 of the arsenate, maybe used and gradually increased. 
It should be used where there is general myasthenia of the stomach 
coats, but would be contraindicated where there is spasm of the pyloric 
muscles. In the latter cases the indications would point toward the 
use of atropine or hyoscyamine. Hydrastin and quassin would be useful 
where there is general relaxation of the stomach and its mucosa. 

Cohnheim has used with good success in some of these cases, 
whether due to organic or spastic conditions, large doses of olive oil. 
Three to four ounces is given as a dose, either through the tube or swal- 
lowed, half an hour before meals. 

Another remedy which has recently been tried with good results in 
some cases is thiosinamin. This has the power attributed to it of dis- 
solving cicatricial tissue, and deserves a trial when the stricture is the 
result of the contraction of the scar tissue in and about the pylorus. It 
may be administered either internally or hypodermatically; by the latter 
method the dose is 0.2 to 0.4 Cc. of a 15 per cent alcholic solution. 

It is of the utmost importance to keep these patients properly 
cleaned out. The tendency is to constipation, and when a fermenting 
decomposing mass is poured into the bowel, there inevitably results 
more or less vitiation of the digestive function of the lower bowel and 
autointoxication from absorption of the decomposing mass. There 
can be no doubt that the anemia, cachexia and many of the nervous 
and metabolic disasters of this disease are due to this cause. In com- 
mencing treatment it therefore is best to be thorough. Administer 
several small doses of calomel, J grain each, using with it small quan- 
tities of podophyllin and of the bile acids when it is desired to secure 
gentle stimulation of the hepatic cells. Follow in a few hours with 
saline laxative in an effervescent form. This should be taken on an 
empty stomach and should be repeated by preference every morning 



ACUTE GASTRIC CATARRH 485 

or at least every other morning. Be thorough, and if necessary to 
insure complete emptying of the lower bowel, wash it out with enemas 
of normal salt solution, so that you can be positively assured that the 
entire intestinal canal is in the best possible condition. It should be 
kept as nearly aseptic as possible by the conjoined use of the sulpho- 
carbolates, as already directed. 

To Epitomize: — The essential things in an uncomplicated case are 
therefore: To keep the bowels well cleaned out as just directed; to 
arrest fermentation and fecal decomposition with the sulphocarbolates; 
to stimulate the mucosa with quassin and hydrastin and the stomach 
musculature with strychnine (when not contraindicated) ; to " brace" 
with the arsenates of iron, quinine and strychnine, with nuclein as cell 
toner; to give the most nutritious diet possible, but one which shall 
have small weight and not generate gases; to give the organ the max- 
imum of rest by the judicious use of the stomach tube. 

ACUTE GASTRIC CATARRH 

This term is used to designate inflammations of the inner coats of 
the stomach which do not penetrate beyond the submucous layers and 
do not terminate in the formation of pus. An inflammation of this 
character affects not only the mucus-producing epithelium but also the 
essential glandular elements of the stomach itself, which furnish the 
substances essential to digestion. 

It is fortunate that in this instance is has been impossible to tie the 
clinician down to the results of postmortem observations, as the tis- 
sues are so markedly altered immediately after death that little has 
been gained by their study. Fortunately it has been possible to study 
this condition during life, as was shown by the investigations of Beau- 
mont on St. Martin. The morbid anatomy is that characteristic of 
other catarrhal inflammations: The tissues are hyperemic, the vessels 
injected, the affected areas swollen and edematous and slight hemor- 
rhagic points may present themselves. Mucus covers the surface, the 
secretion of the gastric ferments is diminished and the cells are swollen 
and granular. 

Symptoms: — Mainly those of "indigestion." There is, in mild cases, 
a sense of fullness and discomfort, more or less burning pain, thirst, 
nausea, eructations and often vomiting. There may or may not be 
slight fever, though this is generally absent. Leube says that the pulse is 
increased in rapidity, but that in case of elevation of temperature some- 
thing else than acute gastric catarrh should be suspected. There is a 



486 ACUTE GASTRIC CATARRH 

diminished secretion of HC1, and lactic and fatty acids are present, 
along with well marked increase in mucous secretion. 

Etiology: — These symptoms are usually due to some well-defined cause; 
in the majority of cases this is some indiscretion of diet, such as 
overeating, the ingestion of foods which are already partially " spoiled" 
or inclined to decompose, the abuse of alcohol or the drinking of bever- 
ages which are too hot or too cold. In a word, anything which may 
cause sufficient local irritation will produce gastric catarrh, whether 
the irritant be chemic, thermic or mechanical. Foreign bodies, swal- 
lowed purposely or not, are not infrequent causes of this condition. 

Diagnosis: — In simple acute " indigestion 1 ' this is not difficult, but in 
febrile attacks accompanied by symptoms of this description it is well to 
withhold diagnosis until the possibility of some acute infectious malady 
may be excluded. Typhoid fever, smallpox, meningitis, scarlet fever, 
etc., may present initial symptoms closely analagous to those described. 
Children, it should be remarked, are much more likely to show febrile 
symptoms as the result of an acute gastric disorder than adults. 

Treatment: — This is comparatively simple. The entire intestinal canal 
should be emptied at once and the stomach put at rest, by abstinence 
from food until the inflammatory condition has subsided. Remove 
any irritating matter from the stomach, preferably by the stomach 
tube; in lieu of this, in mild cases, a mild emetic may be administered. 
A draught of warm water may be sufficient and serves to wash out the 
stomach. If the water is slightly alkalinized, either by the tube or 
without, it will serve to aid in the removal of any tenacious mucus. In 
some cases a hypodermic of apomorphine may be necessary, avoiding 
the possibility of undue depression by the conjoint use of strychnine 
or digitalin. 

The bowel should also be immediately cleaned out. Use an enema, 
with saline solution. Small doses of calomel, J grain or less every half 
hour will not only produce free catharsis but help to settle the stomach. 
When the digestive tract is thoroughly cleaned out from one end to the 
other the vomiting and other symptoms usually promptly subside. Then 
follow up promptly with a saline laxative, efL magnesium sulphate. 
Bismuth helps to relieve nausea and in severe cases small doses (i-io 
to J drop) of carbolic acid or cocaine (1-67 to 1-12 grain) may be tried. 
The following gastric sedative combination is good: Resorcin, gr. 1-40; 
cocaine mur., gr. 1-100; atropine sulph., gr. 1-2500; delphinine, gr. 
1 -1000. A sinapism or a hot turpentine stupe applied to the epigas- 
trium will often control the nausea. Where other means fail a hypo- 
dermic injection of morphine and atropine will usually be found effective. 



TOXIC GASTRITIS 487 

Withhold all food until the symptoms are ameliorated and then 
feed cautiously with non-irritant and semi-liquid foods until the diges- 
tive organs are again able to take up their regular work. 

PHLEGMONOUS GASTRITIS 

This exceedingly serious, but fortunately rare disease of the stomach 
is characterized by the presence of a suppurative process in the mucosa 
of the stomach. It may be a primary idiopathic disease and in these 
cases the cause is obscure; or it may be secondary, a metastatic process 
occurring in the course of some acute form of sepsis, as puerperal fever, 
pyemia or some severe infection. Osier descibes two forms: a diffuse 
septic inflammation; and a localized gastric abscess. 

The symptoms are those of sepsis: Fever, occasionally alternat- 
ing with chills, weak, thready pulse, collapse, delirium and coma pre- 
ceding death. There is pain in the stomach, abdominal pain, with 
meteorism, diarrhea. Vomiting is present but the vomitus, strangely 
enough, rarely contains pus. Sometimes there is jaundice. The 
diagnosis is exceedingly difficult if not impossible. These patients 
usually succumb. 

The treatment is entirely symptomatic. The bowels should be thor- 
oughly cleaned out and kept as antiseptic as possible by enemas con- 
taining the sulphocarbolates. Saturation with calcium sulphide is 
indicated where it can be retained. Support with strychnine arsenate, 
digitalin and glonoin is of course indicated. Ergotin has recently been 
suggested for these cases and since it can be administered hypoder- 
matically it should be given a trial. 

TOXIC GASTRITIS 

This form of gastritis is due to the swallowing of toxic or corrosive 
agents, such as strong acids or alkalies, phosphorus, arsenic, corrosive 
sublimate, etc. Carbolic acid is a favorite poison and caustic very 
frequently taken for suicidal purposes. All of these substances set up 
a destructive inflammation, varying according to the nature of the nox- 
ious agent and the amount ingested. 

The symptoms which present in these cases are violent pain in the 
stomach, difficulty of swallowing, vomiting, the vomitus often blood 
stained and presenting characteristic evidence of the poisonous sub- 
stance. There is also, in severe cases, collapse, feeble pulse, cold clammy 
sweat, etc. Sloughing not infrequently occurs and the broken down 
tissue may be found in the vomitus. 



4SS CHRONIC GASTRIC CATARRH 

The treatment is adressed to the cause. Consult works on Toxi- 
cology. The proper antidote should be given and after proper empty- 
ing of the digestive tract and the support necessary to retain what vital 
force remains, the stomach should be placed absolutely at rest and 
rectal feeding given until the inflammatory reaction subsides. 

CHRONIC GASTRIC CATARRH 

Etiology: — Chronic catarrh of the stomach in most cases is 
caused by errors of diet, especially by eating food which is irritating; 
either too rich or too coarse; too hot or too cold; imperfectly masti- 
cated, bolted whole, eaten at irregular and inopportune hours, or too 
highly flavored with spices or condiments. The use of alcohol in large 
quantities is especially prone to produce catarrh of the stomach and 
by many is considered its most frequent cause. While it undoubtedly 
causes some of the most exaggerated types of this disease it is now 
recognized that a still larger porportion is due to the more common 
indiscretions of diet which we have mentioned. 

Predisposing causes include anything which causes a local- venous con- 
gestion, such as is likely to follow obstruction of the vena cava or the 
portal circulation. These include diseases of the lungs, heart and liver. 
.Anything which impairs the general nutrition and causes general debility 
may also act as a cause; under this head we include the more severe 
forms of anemia, tuberculosis, syphilis, gout, diabetes, malaria, etc. 

Pathology: — The morbid anatomy of chronic gastric catarrh re- 
sembles that of inflammation of mucous membrane anywhere in the 
body. The mucosa is swollen, its vessels injected and there are here 
and there points of slight ecchymosis. As the inflammation progresses 
there is infiltration of the connective tissues with resulting overgrowth. 
The stomach shows an increased secretion of mucus which adheres 
closely to its walls. The tubular cells soon become swollen. Cloudy 
swelling sets in and degeneration ensues, the glandular crypts becoming 
clogged with epithelial debris. Finally, as a result of this degenerative 
process and the contraction of the connective tissue, the glandular ele- 
ments are gradually destroyed, at hrst by individuals, then in small areas, 
the destructive process in the end wiping out, in rare cases, practically 
all of the secreting surface of the stomach. 

While the muscular structures of the stomach are not at hrst directly 
affected, in the course of time their energy is impaired and they become 
incompetent to do the work intrusted to them — the prompt emptying 
of the stomach at the close of the normal period of digestion. 



CHRONIC GASTRIC CATARRH 489 

Symptoms: — In the majority of cases the symptoms of gastritis 
depend upon the following factors: (1) The reduction of the HC1 and 
ferments (pepsin and rennin); (2) the accumulation of mucus and (3) 
deficient motility which causes stagnation of food. 

The presence or absence of HC1 in the stomach should be deter- 
mined in every case in which it is not contra indicated (cancer or ulcer 
of the stomach, advanced disease of the lung or heart and aortic aneur- 
ism) by the use of the test meal, which is to be withdrawn by the stomach 
tube and examined for HC1. The meal most frequently used for this 
purpose is that of Boas and Ewald consisting of a dry roll or a slice of 
bread with a glass of water or a cup of tea drank without sugar or milk, 
taken on a empty stomach. At the end of forty-five minutes or one 
hour this should be withdrawn and the quantity of free HC1 is deter- 
mined by the dimethylamidoazobenzol test. The percentage of this acid 
in health varies from 0.15 to 0.25 per cent. The total acidity due to free 
and combined acids, may' be determined by the phenolphthalein test. 
The technique of these tests will be found in any good work on diagnosis. 
Every physician should familiarize himeslf with these simple tests; they 
are easily made, require no special skill, and yet throw great light upon 
the recognition of diseases of the stomach, and therefore aid in their 
successful treatment. 

In chronic gastric catarrh there is almost always a reduction of the 
HC1 and in some cases — those in which the secreting gastric glands 
have been entirely destroyed by the inflammatory process — the HC1 
is entirely absent. On the other hand it cannot be denied that there are 
occasional cases, described as acid gastritis, in which the amount of HC1 
is not diminished and may be increased. Boardman Reed in his excel- 
lent work upon the "Diseases of the Stomach and Intestines " lays much 
stress upon these cases, which he believes to be relatively frequent. 
Other authors, however, consider acid gastritis a very uncommon dis- 
ease and that is the experience of most of us. The majority of these 
cases are undoubtedly a secretory neurosis which we have described 
under the term Hyperchlorhydria (which see) or at least trans- 
itional states, since prolonged excess of HC1 is likely to result in a more 
or less chronic inflammatory reaction. In cases of acute gastritis there 
is also an increased secretion of mucus; thus they differ from the secre- 
tory neurosis, hyperchlorhydria. 

Mucus is invariably found in the stomach washings or vomitus, with 
the rare exception of cases in which the inflammation has progressed 
to the stage of the complete destruction of the secreting membrane. In 
such cases, there is of course no mucus to be found, as there is no HC1 



490 CHRONIC GASTRIC CATARRH 

or pepsin. These cases of achylia gastrica with complete destruction 
of mucosa are, however, uncommon. 

In examining stomach washings or vomitus remember that there is 
normally some mucus found; but when it occurs in extensive glairy 
sticky masses or strings, then there is presumptive evidence of a catarrhal 
inflammation. Associated will be found, upon the use of the microscope, 
epithelia, sarcina, yeast fungi and bacteria. 

Early in the disease, while the musculature is still unimpaired, there 
may be no symptoms of the disease, for if the organ empties itself 
promptly into the intestines, the lower portion of the digestive tract is 
able to take up the work , which has been partially completed in the stom- 
ach, so that no impairment of health will be apparent; but sooner or 
later, in the majority of cases, the energy of the muscles becomes lessened. 
The result is food stagnation and to this most of the symptoms of which the 
the patient complains are due. The food is retained in the stomach 
until it undergoes various fermentative and putrefactive changes. There 
is gas formation, causing a sensation of fullness and discomfort. Organic 
acids are formed which add to the discomfort. Other results are more 
or less diffuse tenderness and burning pain, nausea, vomiting, a broad, 
coated tongue, often reddened at the tips and sides, an impaired or irreg- 
ular appetite with a craving for acids and salted foods, thirst, salivation, 
regurgitation of food, belching of gas, heartburn, etc. As a result of the 
absorption from the intestinal tract of the products of this imperfect 
digestion the patient presents the symptoms of autoxemia, such as head- 
ache, dizziness, insomnia, physical and mental depression; he is easily 
fatigued, complains of palpitation of the heart and possibly of dyspnea 
—these symptoms leading him to believe that he suffers from disease 
of the heart 

When food stagnation persists the muscles of the stomach become 
permanently thinned and weakened and dilatation or gastrectasis is 
the result. The accumulation of food or fluid or the accumulation 
of gas, now intensifies the distress and adds to the seriousness of the dis- 
ease. 

Vomiting is a common symptom. It may occur from half an hour 
to two or three hours after meals, but in persons who use alcohol to excess 
(alcoholic gastritis) there is morning vomiting) the patient upon rising 
throws up a large amount of frothy fluid mixed with much mucus and 
some food debris; then, after his morning "nip", he feels equal to the 
cares and labors of the day. "Morning vomiting" is considered quite 
characteristic of alcoholic gastritis — indeed, a large percentage of 
alcoholics reach this stage sooner or later. 



CHRONIC GASTRIC CATARRH 491 

Prolonged gastritis invariably results in impairment of nutrition 
especially when, as is likely to occur sooner or later, the compensatory 
power of the intestine fails. Then there are likely to ensue bowel troub- 
les, especially diarrhea alternating with constipation. The skin be- 
comes sallow, dry and rough. As the HC1 secretion is diminished the 
urine is high colored and remains permanently acid; the patient loses 
flesh and becomes debilitated and anemic. It is an interesting fact that 
a large portion of the cases of pernicious anemia, so-called, are asso- 
ciated with atrophic catarrh of the stomach. Whether this is a cause of 
the anemic state or is coincident with it, has not yet been determined. 

Diagnosis: — In chronic gastric catarrh we should keep in mind 
the following points: (1) that there is a diminished HC1 secretion; 
(2) increased secretion of mucus; (3) a tendency to stagnation of food 
and gastric dilatation. 

Decrease of HC1 occurs occasionally as a neurosis (hypochlorhydria) 
but in the neurosis there is never an increased secretion of mucus, as 
in chronic gastritis, and the amount of HC1 in the majority of cases 
varies considerably from time to time; in gastric catarrh it is fairly constant. 

In cancer of the stomach there is also a diminished secretion of HC1 
and there may be also considerable mucus, but the mucus is usually mixed 
with blood, making a dark and grumous mess, the so-called coffee-ground 
vomit. Moreover, the pain of cancer of the stomach is much more severe, 
much more constant; there are cachexia, rapid loss of weight and usually 
a tumor that can be detected upon examination. In cancer, moreover, 
while HC1 is usually absent, or at least greatly reduced, -lactic acid is 
greatly increased. 

Probably no disease of the stomach is so often diagnosed as gastric 
catarrh as hyperchlorhydria and yet the two diseases are not a particle 
alike and the treatment is almost diametrically opposed. In hyperchlor- 
hydria we are dealing with a disease in which there is no marked change 
of structure if there is any; in gastric catarrh there is marked alteration 
of the mucosa. In hyperchlorhydria there is an increase in the amount 
of HC1 secreted; in gastric catarrh there is a decrease. In hyperchlo- 
rhydria the digestion is only slightly impaired, not at all, as regards pro- 
teids; in gastric catarrh the digestion is very much impaired and that 
of proteids is peculiarly weak. In hyperchlorhydria there is no excess 
of mucus; in gastric catarrh there is a decided excess. In hyperchlo- 
rhydria the pain comes on one to three hours after meals, at the height 
of digestion, and is due to the irritation of the caustic acid; in gastric 
catarrh the pain comes on soon after eating and is due quite as much 
to the distention of the stomach with stagnated food, and to the gases 



492 CHRONIC GASTRIC CATARRH 

which are developed in it, as to any local irritation. Hyperchlorhydria 
is relieved by partaking of food and the use of alkalies; neither of these 
modifies the discomfort of gastric catarrh — except for the worse. These 
two diseases make up the vast bulk of the stomach diseases which the 
physician is called upon to treat. It is therefore vastly important that 
he should be familiar with their pathogenesis and symptomatology that 
he may treat them intelligently. The absurdity of " stock prescriptions" 
for the treatment of "indigestion" or "dyspepsia" cannot be too 
strongly insisted upon. Every physician should know what he is treat- 
ing. The standard formulas of "mix," pepsin, hydrochloric acid and 
the bitter tonics have a very restricted usefulness. 

Ulcer of the stomach is more common in young women while 
chronic gastritis occurs in older people. In ulcer there is increase of 
HC1, severe pain on taking food, and definite local tenderness; the 
tenderness in gastritis is diffuse. In ulcer there are usually hemorrhages 
and these are uncommon in gastritis, and when they do occur, slight. 

Prognosis'. — Chronic gastritis is a serious disease and deserves 
careful attention. If allowed to develop it may, and often does become 
a fatal disease, setting up, as a result of the profound disturbance of 
nutrition, a weakened state in which the body is incapable of resisting 
the incursions of disease. We have already referred to its relation to 
anemia. It is also true that, in all probability, chronic gastric catarrh 
is a precursor of such serious visceral diseases as cirrhosis of the liver, 
for instance. If treatment is instituted before profound alterations of 
structure have resulted the outlook is good for its arrest but it should 
be remembered that no treatment can restore tissues once destroyed. 

Treatment: — In chronic gastric catarrh the first aim should be 
to minimize or remove the causes which have produced the trouble. In 
case the disease is due to disease ©f the heart, lungs or liver these 
organs should have first attention. To relieve the passive conges- 
tion under these conditions remedies Which raise the arterial tension, 
such as digitalin, strychnine, etc. ; are indicated; whiie drainage into 
the intestine by the administration of saline laxatives is particularly 
indicated in cirrhosis of the liver. 

In most cases, however, the trouble is due to some vice in diet or 
the abuse of alcohol. An effort should be made to secure the correc- 
tion of these faults, for so long as the cause persists no permanent ben- 
efit can be anticipated. The delush e advertisements of pills and potions 
which promise to make it possible for the dyspeptic to "eat anything 
and everything" are worse than a delusion, since they persuade the 
patient to persist in the evil habits which are the cause of his ill-health. 



CHRONIC GASTRIC CATARRH 493 

The indications for treatment briefly epitomized are as follows: (1) 
To prevent further irritation of the already inflamed mucosa; (2) to 
raise the nutrition by selecting food capable of digestion by the feeble 
gastric juices; (3) to combat food stagnation; (4) to prevent auto- 
toxemia; (5) to secure proper vascular equilibrium. 

The first indication is met, in most cases, by supervision of the diet. 
To enter into detail we must cover the whole subject of diet and this is 
by no means an easy matter. No hard and fast rules can be laid down 
concerning the foods most suitable for the sufferer from gastric catarrh. 
Each patient requires individual treatment. In general, however, it may 
be said that the food should not be irritating, that is, contain substances 
which directly stimulate the mucous membrane. Contraindicated, there- 
fore, are very hot or very cold food or drink, alcohol in almost any form, 
tea and coffee in the majority of cases, pickles or other highly acid food, 
spices, condiments and foods which are mechanical irritants such as coarse 
bread with its attendant bran. Also to be omitted from the diet are foods 
which are rich in sugar, as sweets, cake, preserves, etc., these things being 
very prone to undergo fermentative changes especially since the HC1 
secretion, which acts as a natural antiferment, is secreted in such feeble 
proportions. Also to be forbidden are all foods which are not easily re- 
duced to a fine pulp by mastication or for any reason cannot be made 
easily accesible, by fine comminution, to the gastric juice. This includes 
practically all fried foods and especially fried meats. Under this head 
would come also the newly made bread, oatmeal and all things which 
are cooked in fat. This instruction is especially necessary to people who 
are accustomed to bolt their food insufficiently masticated. The necessi- 
ty for this precaution is due to the fact that the gastric secretions are so 
scanty that it is necessary to put every particle of food into the physical 
shape most accessible to contact with the acid and ferments of the stomach. 
Masses of food are digested with difficulty even by a normal stomach; food 
which is saturated with hot oil is also almost impervious to the action 
of HC1. 

With these prohibitions the physician must commence tentatively to 
formulate a diet which will meet the patient's idiosyncrasies. As a gen- 
eral rule, an account of the tendency to dilatation of the stomach, the meals 
itaould be small and frequent, usually five meals a day, that every particle 
of food may be utilized. If the case is a moderately severe one it is bet- 
ter to commence with food which is in the liquid form, for instance many 
physicians commence with milk or cream. This may be given with or 
without raw eggs. Purees of vegetables are nutritious, and pleasant for 
many individduals. Soups or bouillons may be useful as alternates: 



494 CHRONIC GASTRIC CATARRH 

The cereals if thoroughly cooked and finely comminuted are desirable. 
In the very severe cases, especially those associated with anemia, the use 
of pure meat juice is excedingly valuable. Dr. Futterer administers in 
this way the juice of five pounds of beef each day. The meat is finely 
chopped round steak mixed with a teaspoonful of salt and placed in a 
double boiler and covered, the lower part of the boiler is filled with warm 
water which is kept at about i2o°F on the back part of the kitchen stove 
for about four hours. The juice is then expressed with a potato masher 
and seasoned to taste. 

As the digestive capacity increases more variety may be allowed, such 
things, for instance, being given as raw or only partially cooked eggs, 
zwieback, finely minced meat, not overcooked, a gradually increasing 
variety of cereals, etc. Keep in mind, however, the necessity of giving 
these patients enough food and a diet which has the proper balance, that 
is, the proper proportion between proteids, carbohydrates and fat. If 
possible the food should be weighed and enough of it given to assure a 
value of from 2500 to 4000 calories according to the weight and work of 
the patient. It is absolutely essential to procure a pure blood supply to 
restore the debilitated condition to a condition of health. 

As regards drinks. Very little fluid should be taken at meal time. 
As a rule tea and coffee are better omitted, though occasionally a half cup 
of coffee after the meal seems to assist rather than retard digestion. The 
cereal drinks which are so common nowadays are usually well relished 
and have the advantage of being nutritious. It is important to bear in 
mind both as regards foods and drinks that a dilated stomach should be 
weighed down as little as possible with anything heavy, hence the im- 
portance of small and frequent meals and the necessity of abstaining from 
large draughts of fluid — water, beer or anything else. 

Too much emphasis cannot be laid upon the necessity of thorough 
mastication. In no stomach disease is this so important as in chronic 
gastritis. There can be no question that if all food were chewed to the 
" disappearing point," as recommended by Horace Fletcher and empha- 
sized by Chittenden, there would be very few cases of chronic gastritis 
or of other stomach disease; also that thorough mastication would do 
much to promote their cure. 

To secure proper distribution of the blood and stimulate nutrition, 
personal hygiene is of the utmost importance. The skin should be stimu- 
lated, providing the patient is not too debilitated, by a cold sponge bath 
or spray upon arising,' followed by vigorous friction. The body should 
be kept warm, especially the extremities and the abdomen, and for this 
purpose silk or wool should be worn next the skin. Exercise in outdoor 



CHRONIC GASTRIC CATARRH 495 

air should be insisted upon, such as walking, bicycle riding, horseback 
riding, rowing, golf, tennis, etc. Where exercises of this kind are not to 
be had a good substitute should be found in suitable gymnastic exercises, 
especially those which develop the abdominal muscles. In some cases 
massage of the abdomen is especially indicated. All these things serve 
to bring the blood to the surface and the extremities, relieve visceral con- 
gestion, help in the elimination of waste, increasing the activity of bowels, 
kidneys and skin, and give increased tone to the entire body. 

Lavage is indicated in nearly every case of chronic gastritis and is 
the most important remedial agent in its treatment. The much abused 
stomach tube finds its most important therapeutic value in these cases. 
The frequency of use depends upon the severity of the case. Occasion- 
ally it may be essential to wash out the stomach twice or even three times 
a day but usually once a day is sufficient. Night or morning is the best 
time, especially if the tube is used only once a day; it should not 
be used until some hours after eating, or until the digestion is en- 
tirely completed. The water should be moderately warm and the 
addition of a little common salt or bicarbonate of sodium facilitates 
the removal of the mucus which coats the stomach wall. Various 
antiseptics may be used through the tube, in solution. Boardman Reed, 
for instance, uses a weak solution of resorcin or a weak solution of alum, 
one-half teaspoonful to the quart. Tannic acid may also be employed 
for its astringent effect (in half the preceding strength) or nitrate of silver 
may be introduced in solution (1 to 2000) in this way. Other remedies 
used thus are boric acid, thymol, and salicylic acid. The essential things, 
however, in the use of the tube are to secure thorough cleansing, the re- 
moval of all adherent and irritant mucus, and then putting the organ at 
rest. 

Hot water is a favorite remedy in the treatment of chronic gastric 
catarrh. It should be drank one or two hours before the expected meal. 
It may be made slightly saline or alkaline as in the case of the solution 
used for lavage. It serves to clean the gastric wall and wash the mucus 
and epithelial waste down into the bowel, while slightly stimulating the 
mucous membrane. It has, the disadvantage of adding to the danger 
of infection of the lower bowel. It is, however, a valuable remedial meas- 
ure, though inferior to the lavage. 

In the medicinal treatment it is of primal necessity to keep the entire 
intestinal tract in the best condition possible. Fecal accumulations should 
be prevented as far as possible by proper hygiene and diet, but in spite 
of these constipation is likely to be a troublesome symptom. Occasional 
cleaning out with calomel and podophyllin and other remedies which 



496 CHRONIC GASTRIC CATARRH 

stimmate the liver (which is a most important organ in gastric catarrh) 
are to be directed; these remedies are to be followed by salines. Indeed, 
in all conditions in which there is a tendency to passive congestion along 
the digestive tract saline depletion is indicated. For this reason many 
of these patients receive benefit at the foreign spas where in addition to 
laxative waters they get the proper diet and hygiene which their cases 
demand. To maintain regularity of the bowel no remedy will be found 
more effective than properly graduated doses of the anticonstipation 
pill (Waugh). 

In chronic gastric catarrh lies a special field for the administration 
of HC1. The dilute acid can be administered in ten to twenty minim 
doses about an hour after eating. The dose may be repeated in half an 
hour if indicated. The HC1 converts the pepsinogen into pepsin and 
helps to check the fermentative processes which so readily develop in these 
cases. Pepsin may be administered though it is rarely needed, the sup- 
ply usually being sufficient to meet the demands of the stomach unless 
a large proportion of its secreting surface has been destroyed. In those 
few cases of atrophic gastric catarrh in w T hich the HC1 secretion and pep- 
sin are entirely absent it is now considered better to treat the stomach 
as part of the intestinal tract and commence at once an alkaline proteolysis 
by the use of alkalies and pancreatin. In the borderline cases, and for 
that matter in almost any case of chronic gastric catarrh, the vegetable 
ferments are of great value, especially the products of the pawpaw, such 
as papayotin, papoid, caroid, etc. The juice of the pineapple contains 
a valuable proteolytic ferment and may occasionally be taken with ad- 
vantage in cases of feeble digestion. 

Antiseptic and antifermentative drugs are undoubtedly of great value 
in cases of gastric catarrh. Boardman Reed speaks well of zinc sulpho- 
carbolate. Personally we have found the combined sulphocarbolates of 
lime, sodium and zinc better and have secured remarkable results with 
them in the treatment of these cases. The antiseptic should not be ad- 
ministered until the process of digestion is at its acme, say one to two 
hours after meals, so that it may not interfere with the evolution of the 
normal ferments. It should then be given with the object of checking 
the fermentation and putrefaction both in the stomach and bowels, a fairly 
odorless stool being the sign of sufficiency. 

Silver nitrate is another intestinal antiseptic which has the advantage 
of acting both as a sedative and a stimulant to the inflamed mucous mem- 
brane. It should be invariably given on an empty stomach, usually be- 
fore meals; the dose is 1-12 to 1-16 grain. Silver oxide may be given in 
the same doses and is perhaps even superior to the other salt. 



CHRONIC GASTRIC CATARRH 497 

As a stimulant to the appetite bitter tonics are usually administered 
in chronic gastric catarrh. In our opinion the best of these is quassin. 
The granules should either be allowed to dissolve in the mouth slowly 
or the remedy should be taken in solution, since its action upon the stomach 
is a reflex one as a result of the stimulation of the gustatory nerve. Orex- 
ine tannate has also been highly recommended for the anorexia. Con- 
durangin also suggests itself as highly applicable in these cases. Hydras- 
tin is one of the best remedies at our command when there is a relaxed 
and atonic condition of the mucous membrane. Strychnine, especially 
in the form of the arsenate associated with iron and quinine is a valuable 
reconstructive tonic and stimulant of appetite. If there is much debility 
and cellular degeneration nuclein should be added. 

For the local effect upon the inflamed mucous membrane bismuth 
subnitrate is also administered in large doses. It may profitably be given 
through the stomach tube after lavage; it is floated upon the fluid which 
is introduced and when the liquid is withdrawn the bismuth remains in 
contact with the stomach wall. It is sedative and said to be highly use- 
ful in cases where there is much mucus and especially in alcoholic gas- 
tritis. 

Electricity is a valuable remedy in these cases of gastritis, especially 
intragastric faradization. 

Vomiting is often an intractable symptom and may require special 
treatment. It usually yields promptly to lavage, especially when followed 
by medicinal treatment. Small doses of calomel with bismuth and ipecac 
have been found effective by the writer, say 1-6 grain of calomel 1-12 grain 
of powdered ipecac and five grains of bismuth subnitrate at a dose. When 
vomiting seems due to a hyperesthetic condition of the stomach carbolic 
acid in one-half minim doses given in solution, with ten-drop doses of 
spirit chloroform with a little glycerin to sweeten and peppermint water 
to make one dram, usually answers nicely. In severe cases minute doses 
of cocaine, 1-67 grain, repeated every fifteen minutes may be necessary, 
though cocaine is a dangerous drug and a treacherous one. Menthol 
sprayed through the tube also acts as a valuable anesthetic to an over- 
sensitive mucous membrane 

To stimulate the weakened muscles of the stomach and bring about 
a reaction of the diseased vessels Turck resorts to the use of an inflatable 
bag attached to the end of his tube into which it is possible to introduce 
fluids at any temperature desired, or which may be employed for inflation 
with air, alternately filling and emptying the bag so as to bring about a 
species of gastric gymnastics. This procedure is undoubtedly effective, 
at times, in skilled hands. 



498 GASTRIC ULCER. 

GASTRIC ULCER 

Ulceration of the stomach is one of the most common causes of "in- 
digestion." In its typical form it is easily recognized, but unfortunately 
its early symptoms are too often obscure and escape recognition. The 
absence of pain and hemorrhage should not mislead the physician into 
an error of diagnosis, since as Boardman Reed points out," it frequently 
masquerades in the garb of a more or less severe dyspepsia. " Any chronic 
indigestion should be carefully investigated. 

Etiology: — The cause of gastric ulcer is not always clear, but it usually 
occurs probably in the presence of and as a result of an excessive secretion 
of hydrochloric acid, when the hyperchlorhydria is associated with 
some general condition which undermines the resisting power of the 
cells of the gastric mucosa. Probably the most common predisposing 
cause is chlorosis. It therefore naturally occurs with greatest frequency 
in young women, early in menstrual life, the greatest number of cases being 
found between the ages of twenty and thirty. Anemia, syphilis, tuber- 
culosis and other debilitating diseases may act as predisposing causes. 
The ingestion of articles of diet which are mechanically irritant or excite 
the secretion of an excess of HC1 favors the incidence of the disease. 
Pressure from without, as occurs with tailors and shoemakers, may also 
exert some influence in producing the disease. 

Morbid Anatomy: — The ulcer is due to digestion of a portion of the 
stomach wall. Just why this occurs in this condition and why the stomach 
does not at other times digest itself has long puzzled physiologists. Prob- 
ably in this condition a small area of mucosa, corresponding with the dis- 
tribution of an arterial twig, is either dead or in a very low state of nu- 
trition, either from general or local causes. Virchow suggests that throm- 
bosis or infarction of the nutrient blood-vessels favors digestion of the 
mucosa. Anemia certainly seems to be an essential factor in the etiology 
of the disease. 

The ulcer is usually located on the posterior wall or lesser curvature, not 
far from the pylorus, which is not infrequently involved. The anterior 
wall, fundus and greater curvature are rarely attacked. The ulcer is 
usually single, round or oval in shape, with well-defined and clear cut 
edges, though rarely it may have serrated borders. It is funnel shaped 
and may penetrate all the layers, even the peritoneal, but its floor is usually 
the muscular coat. In size it is usually small, one-half an inch or less in 
diameter, but rarely the diameter may reach several inches; these large 
ulcers are usually the result of the coalescence of several small ulcers. 
An ulcer may perforate the walls of a vessel and cause hemorrhage, the 



GASTRIC ULCER 499 

amount of blood lost depending upon the size and importance of the 
vessel. MTien spontaneous cures take place, as not infrequently happens, 
scar tissue is formed; these cicatrices are frequently found in persons 
who have died from other causes and in whom a serious disease of the 
stomach was unsuspected. If the ulcer penetrates the peritoneal coat 
an opening may be made into the peritoneal cavity, the bowel, the pleural 
cavity, or even externally; or the cicatrix which it leaves behind may 
cause stenosis of one of its orifices, usually the pylorus. 

Symptoms: — The most characteristic symptoms of ulcer are: (1) Pain, 
which has a distinct relation to the taking of food; (2) localized tender- 
ness; (3) gastric hemorrhage, blood appearing in the vomit or stool; 
(4) an excessive secretion of hydrochloric acid. 

If there is associated with the symptoms more or less marked anemia or 
other evidence of malnutrition the diagnosis of ulcer may safely be made. 
And yet, as already pointed out, the absence of these symptoms will not 
warrant us in positively excluding it. 

The most constant and characteristic symptom of ulcer of the stomach 
is pain. This comes on soon after eating, usually within half an hour, 
and is intensified by taking food; it usually disappears when the stomach 
is empty. It is burning or boring in character, diminished by rest and 
certain postures, localized to a circumscribed area in the epigastrium 
which the patient will learn, and often passes through the body, felt 
between the shoulder blades or along the spine, especially on the left 
side, or radiated in various directions. Liquid food causes less pain 
than solid food. 

The tenderness is usually confined to a rather small area in the epi- 
gastrium seldom much larger than a silver dollar, located either in the 
middle line or a little to the left, and an inch or two below the xiphoid. 
This location, however, varies considerably and is of course dependent 
upon the seat of the ulcer. A similar tender point is usually to be 
found in the back, near the junction of the lower two or three ribs of the 
left side and the spine. 

Hemorrhage is a common and important symptom. If its source is 
arterial and the quantity is considerable the patient vomits up bright 
red blood; if it comes out more slowly from an eroded vessel, the blood 
is partially digested and ejected as the so-called " coffee-ground " vomit. 
If the quantity is small and vomiting does not occur the blood passes 
into the bowels and gives a peculiar tarry consistency and appearance 
to the stools. If the ulcer occupies a non-vascular location there may 
be such slight capillary oozing that blood does not appear, either in vomit 
or stools, in microscopic quantities. 



5 oo GASTRIC ULCER 

An excessive secretion of hydrochloric acid occurs, according to Hem- 
meter, in 88 per cent of the cases. It is a very constant symptom and 
its recognition of much diagnostic value. Organic acids are absent. 
The use of the stomach tube is to be avoided, especially if hemorrhage 
is recent or a deep ulcer is at all suspected. 

Vomiting is a very common though not a constant symptom. It 
usually occurs at the height of digestion and is followed by a cessation 
of the pain. The vomitus consists of partially digested food, highly 
acid and frequently containing blood. 

Diagnosis: — In well defined cases it is usually easy, but in many 
it presents considerable difficulty. The characteristic symptoms are 
(i) hydrochloric acid excess; (2) severe pain in the stomach coming 
on soon after eating and associated with local tenderness; (3) hemor- 
rhage from the stomach, with or without tarry stools. It is in cases in 
which one or more of these symptoms are absent that confusion arises 
as to the diagnosis. 

An excess of hydrochloric acid occurs in the neurosis, Hyperchlor- 
hydria. This symptom is, however, seldom constant in the latter cases, 
and varies greatly in its intensity. In hyperchlorhydria also the pain 
is relieved by taking food, while in ulcer this intensifies it. 

Hemorrhage is also a symptom of cancer of the stomach; but in the 
latter disease there is associated cachexia and the vomit shows the blood 
in a more decomposed and darker condition. In cancer,, HC1 is usually 
absent, and there is an excess of lactic acid. 

In chronic gastritis there is usually a reduction in the quantity of HC1, 
though in the form known as acid gastritis it may occur in excess; 
blood is absent or at the most slight tinges may appear; mucus and 
epithelial fragments are found; pain is not present, except as a sense of 
discomfort. 

In gastralgia the paroxysms have no relation to the taking of food. 

Hepatic colic also presents paroxysms of pain, but not connected 
with eating. There is no hemorrhage. Jaundice usually follows the 
attack and an examination of the stool shows the presence of one or 
more gallstones. 

Prognosis: — This is always a serious disease and every case in 
which it is suspected should have the most painstaking examination in 
order to establish the diagnosis. Perforation of the ulcer may cause 
peritonitis, pleurisy, pneumonia, etc. If the ulcer erodes a large vessel 
a dangerous and possibly fatal hemorrhage will result. It is now a well 
established fact that the seat of an ulcer or the cicatrix following it may 
be the point of localization for a carcinomatous growth. 



GASTRIC ULCER 501 

Treatment: — In the treatment of gastric u'cer it is essential that 
the stomach should be placed as nearly at rest as possible. The patient 
should therefore be put to bed and absolute quiet insisted upon. In 
order to secure the maximum of rest for the stomach, feeding for the first 
week after treatment is commenced should be entirely by the rectum; occa- 
sionally stomach feeding will answer in very mild cases, alkalinized milk, 
malted milk, or beef juice being the main foods. The food should be 
administered by an enema every four to six hours in quantities of four 
to six ounces at each feeding. Before administering the food, the 
rectum should first be carefully emptied by enema and irrigated with 
a normal salt solution. 

Various food preparations can be administered by this route, such 
as peptonized milk, peptonized gruel, beef juice, bovinine, milk, raw 
eggs, somatose dissolved in milk or water, etc. To every enema a little 
salt should be added to facilitate absorption and if the bowel is at all 
irritable the addition of a few drops of tincture of opium, or better still, 
of about a quarter a grain of morphine in solution, is desirable. 

After a week or ten days, if the patient shows improvement, feed- 
ing by the mouth should be gradually resumed. First, commence with 
a little milk diluted with lime water or vichy, egg albumin water, liquid 
peptonoids or malted milk. If milk is given it is well to have it pep- 
tonized at the start. 

The amount of food is to be gradually increased as the tolerance 
of the stomach improves. If any evidence of irritation arises in the 
stomach the food given by the mouth may be temporarily stopped, or 
at least the quantity of food given by this route diminished, and rectum 
feeding resumed. Following this course the amount of food by the 
stomach is gradually increased while that by the rectum is gradually 
diminished until the food is all taken by the natural route. 

The patient should be kept in bed during all this time and it may 
be necessary to keep him there for weeks and months. 

As regards medication; sodium bicarbonate may be administered 
to counteract the excessive flow of hydrochloric acid. The patient may 
be directed to drink some alkaline mineral water, especially those which 
are laxative, since constipation is often a troublesome symptom in 
some of these cases. 

To check the flow of hydrochloric acid and to relieve the spasmodic 
and painful condition of the stomach, the indicated drug is atropine. 
It may be given to slight physiological effect for a long period of time. 
Nitrate of silver, given in pill form, in doses of one-fourth to one-half 
grain is a favorite remedy for its direct local effect upon the stomach. 



502 CANCER OF THE STOMACH. 

Fleiner's method of treating these cases was by the injection of large 
doses of bismuth subnitrate; after washing out the stomach with a tube, 
two and one-half drams suspended in water are introduced into the viscus 
and the water gradually withdrawn. This brings the bismuth in direct 
contact with the walls of the organ, thereby reducing local irritability 
and facilitating the healing of the ulcer. 

Hemmeter introduces the bismuth through a powder blower. The 
disadvantage of this mode of treatment is that in many cases the intro- 
duction of the tube is dangerous, especially if the ulcer has penetrated 
the more superficial layers and now has reached the deeper muscular 
or possibly the peritoneal coats. In such cases there is danger of punc- 
ture, which may be directly induced by the use of the stomach tube. 

In cases of hemorrhage, the patient should be kept on his back, 
absolutely still, not being allowed to move hand or foot. Neither food 
nor drink, with the possible exception of a little ice, is allowed. An 
ice-bag should be placed over the pit of the stomach and perfect quiet 
secured by a hypodermic of morphine. If the hemorrhage is associated 
with considerable shock the circulation may be equalized by repeated 
doses of glonoin, atropine, and strychnine. Perforation should be 
treated the same as shock. 

CANCER OF THE STOMACH 

Next to the uterus the stomach is the most frequent site of cancer. 
The investigations of Welch showed that 21.4 per cent of 30,000 cases 
which he investigated were located here. It occurs rather more fre- 
quently in males than in females, in the proportion of about 5 to 4. 
Gastric carcinoma is a disease of advanced middle life, about 58 per 
cent occurring between 40 and 60; nevertheless it occurs at all ages. 

Etiology: — Previous stomach trouble seems to play a slight part 
in its causation; in 150 cases admitted to the John Hopkins Hospital 
Osier found a history of indigestion in but 33. It is, however, con- 
sidered highly probable that many cases of stomach cancer owe their, 
existence to a previous ulcer, being implanted upon scar tissue. Once 
in a while there seems to be a history of injury, and indulgence in 
alcohol may occasionally predispose to its incidence. But in the 
majority of cases the disease is primary but occasionally it is secon- 
dary to carcinomatous infections elsewhere, especially of the breast. 

Pathology: — The growth originates in the glandular elements of the 
mucosa, from which it has a tendency to spread to the submu- 
cosa and muscular layers of the stomach, with metastatic infection through 



CANCER OF THE STOMACH 503 

the lymphatics of other portions of the body. There are four common 
varieties of cancer of the stomach, occurring in about the following 
order: (1) Adenocarcinoma, a nodular cancerous growth in which 
the glandular element is prominent, the tissue presenting a large amount 
of tubular structure, lined with cylindrical epithelium. There is white 
cell infiltration of the stroma, which is abundant. (2) Medullary 
carcinoma. The cancerous growth is large, rapidly involving large 
areas in the stomach wall, consists of soft cauliflower-like masses which 
break down easily and bleed. The connective tissue stroma is rather 
scanty and the cellular element prominent. There are irregular alveolar 
spaces, lined with cells which are polyhedral or cylindrical. (3) Scir- 
hous. In this form the cancer is hard and resistant, consisting most 
largely of connective tissue. There is a predilection for the pylorus. 
(4) Colloid. These cancerous growths belong to the type of the 
medullary 7 growths, containing large alveolar spaces which become 
filled with gelatinous matter. They grow rapidly and involve large 
areas. 

The seat of involvement in cancer of the stomach is most frequently 
the pylorus; according to Brinton this portion of the stomach was 
attacked in 60 per cent of his 360 cases. In 10 per cent the cardia 
was attacked, the remaining 30 per cent being distributed over various 
areas. The fundus rarely suffers. If the pylorus is the seat of the 
disease the stomach is usually dilated; if the cardia, it may be consider- 
ably contracted. The softer forms of cancer, the medullary and col- 
loid, show the most rapid growth. Metastatic growths soon form in 
the neighboring glands, liver, gall-bladder, peritoneum, omentum, etc. 
Not infrequently these growths may be found subcutaneously in the 
epigastric region or around the navel, in which cases they are a valuable 
diagnostic sign. 

Symptoms: — The first symptoms are those of indigestion, and 
are more or less obscure. As the disease progresses there is emaci- 
ation, loss of strength and anemia. These symptoms may make 
their appearance very gradually or very rapidly, according to the type 
of the cancer and the rapidity of its growth. There is usually loss of 
appetite, a dry coated tongue, nausea and a gradually increasing sense 
of discomfort, growing in severity until it becomes an actual pain, drag- 
ging, gnawing or burning in character. 

Vomiting may be absent "and is a fairly constant symptom, espe- 
cially late in the disease, when there is obstruction of the pylorus. It 
usually does not occur immediately after eating, but the ejected mat- 
ter usually shows that the food is not being w r ell digested. 



504 CANCER OF THE STOMACH 

Hemorrhage occurred in 36 out of 150 cases reported by Osier, 
the vomited matter usually being dark or " coffee ground" in charac- 
ter — rarely bright red. Careful examination of the vomitus usually 
reveals the presence of blood. 

Anemia is quite constant. The number of red blood cells may be 
reduced a half while the percentage of hemoglobin is often below 50. 
There is leucocytosis. After the development of anemia there is likely 
to be some ascites around the ankles in the later stages of the disease 
and, rarely, anasarca. The skin takes on a peculiar lemon-colored 
tint which i's quite characteristic. 

Pain, as already said, is a very common symptom and occurs rela- 
tively early; it may be referred to the pit of the stomach, or to the back 
or shoulder blades. It is constant but is generally aggravated by tak- 
ing food. 

Fever usually occurs sometime during the disease but is not a con- 
stant symptom; the elevation of temperature is rarely high. 

Constipation is the rule and blood may usually be found in the 
stools. The urine often shows no changes, but sometimes there are 
albumin and casts; occasionally indican; and more rarely glucose, ace- 
tone and peptone. 

Upon physical examination a tumor may be detected in a large per- 
centage of cases; but where the growth is at the cardia or on the pos- 
terior wall of the stomach it is often impossible to palpate it., The 
tumor when felt is usually easily movable, changes its position with 
respiration and peristalsis and with the pulsations of the abdominal 
aorta. 

Examination of the stomach contents is of great value in the diag- 
nosis of cancer of the stomach. In the majority of cases HC1 is entirely 
absent — it used to be thought invariably so, but this has been shown 
not to be the case. Probably where the cancer has been inplanted upon 
gastric ulcer the HC1 secretion is more likely to persist. After the 
Boas meal of oatmeal gruel if there be cancer lactic acid will usually 
be found. This is a valuable sign of this disease. The Oppler-Boas 
bacillus is also found in the stomach contents; this is thought to be the 
cause of the formation of the lactic acid. Yeast is also present but sar- 
cinae are rare. The stomach washings will also reveal in many instances 
fragments of the growth, blood, etc. which aid in the diagnosis. 

Diagnosis: — During the early stages the diagnosis is very difficult 
and may be impossible. Where there is persistent indigestion in a per- 
son of middle age, with more or less constant pain in the stomach or 
associated areas, with anemia and emaciation, the physician should be 



CANCER OF THE STOMACH 505 

very suspicious. Gastritis is a very chronic disease and as a rule the 
blood changes and anemia are not so pronounced; it should be remem- 
bered however that in some forms of gastritis there is a distinct ten- 
dency to anemia of the pernicious type, and in these cases the nutri- 
tional changes are very marked. Ulcer of the stomach has within recent 
years been the source of a great deal of confusion; many cases that 
have been diagnosed as gastric ulcer after examination of the stomach 
contents, have turned out to be carcinoma. As a rule, however, ulcer 
occurs in younger patients and the presence of HC1 in excess and the 
absence of lactic acid clears up any doubts as to the nature of the 
trouble. The grave anemias often present a clinical picture that may 
be taken for cancer, especially where there is associated indigestion, as 
is not infrequent. In pernicious anemia the number of blood cells is 
much less than in cancer — may fall below the million. Stomach con- 
tents should be examined. 

Prognosis: — Cancer of the stomach is of course a fatal disease. 
The patient usually dies within a year or eighteen months. 

Tredtmenfc — Mainly palliative, addressed to the maintenance of 
nutrition and the alleviation of pain. Often the rapid emaciation 
may be temporarily checked by careful attention to the diet, the use of 
concentrated and easily digestible — possibly predigested — food, wash- 
ing out the stomach, attention to the bowels, etc. 

A remedy which has been recommended for cancer (and in some 
cases this remedy has certainly produced remarkable results) is con- 
durangin. While this is not claimed to be a "cure" for cancer it 
deserves a more thorough trial. It certainly relieves the pain and in a 
large percentage o cases favors nutrition. 

Observations on hundreds of cases have shown that in almost every 
case this remedy exerted a decidedly beneficial action, and a consider- 
able number were discharged apparently cured. Autopsies held on 
several who died from other maladies are said to have confirmed the 
diagnoses. A remarkable observation was that the benefit was only 
manifested on cancers of the stomach, while similar maladies of the liver 
and pancreas were not benefited. This seems to indicate that the action 
is a purely local one. Nevertheless we have been unable to find any 
evidence showing that any investigator has applied condurango locally. 
This plant depends for its activity upon a glucoside, condurangin. This 
has been isolated and may be employed hypodermatically. It seems that 
there is a legitimate field for experiment with it in inoperable carcinomas. 

For gastric cancer the glucoside may be given in doses of gr. 1-67, 
three times a day, in a little hot water, when the stomach is empty, and 



506 GASTRIC NEUROSES. 

this may be gradually increased to the limit of toleration, and continued 
as long as the need demands. 

HEMATEMESIS 

Vomited blood may be derived from the throat, esophagus, stomach 
or perhaps the duodenum. The hemorrhage may be from injury to 
these parts; disease such as carcinoma, ulcer, aneurism, or acute hyper- 
emia; portal stasis; vicarious menstruation; affections of the blood tend- 
ing to cause hemorrhage, such as scurvy and hemophilia; and disease 
of neighboring parts that perforates the cavities mentioned. The diag- 
nosis of hematemesis depends on the condition of the blood, which is 
usually clotted or disintegrated by the gastric secretions as in the black 
vomit of yellow fever. It is acid and contains food elements. Nausea 
attends the hemorrhage. The diagnosis of the causal disease is to be 
made by a study of the preceding and accompanying symptoms. Blood 
from a bursting aneurism or an eroded artery may be bright and fluid. 
Malingerers who vomit dark fluids may be detected by examining the 
vomitus with the microscope, and by the absence of concomitant symp- 
toms. The prognosis depends on the cause. 

The best treatment for any internal hemorrhage consists in the use of 
atropine, gr. 1-134 every half to one hour till the blood reddens the skin. 
The blood crasis may be improved by giving lime salts, the lactophos- 
phate, in doses of grs. 10 daily, divided, for months. 

GASTRIC NEUROSES 

Definition: — Under the term, gastric neuroses, are included the 
various ailments of the stomach caused by disturbance of the innerva- 
tion of this viscus and in which there is no demonstrable pathologic lesion 
of the organ itself. 

The term, nervous dyspepsia, was formerly much employed to desig- 
nate various mixed gastric neuroses, and it is still used by some authors 
to describe a symptom-complex which differs greatly in different cases, 
but in which the local and general sensations which commonly follow 
a full meal are exaggerated in intensity and accompanied by alterations 
of taste and appetite, eructations, pyrosis, nausea, headache, vertigo and 
diffuse tenderness — the digestion meanwhile taking its normal course 
and being completed in its normal time. 

Etiology: — Neurasthenic and hysteric conditions are the most com- 
mon predisposing causes. Ailments of this class are most frequently 



NEUROSES OF MOTION. 507 

seen in women; they may be the result of mental overwork, physical 
exhaustion, nervous strains or psychic shocks, sexual excesses, alcoholic 
indulgence, improper food or overeating, gulping the food, insufficient 
exercise, etc. In many cases the trouble is reflex; thus gall-bladder 
disease, disease of the pelvic organs in females, pregnancy, autotoxemic 
states, nephritis, central nervous disease (locomotor ataxia), etc., may 
act as causes of stomach trouble. 

It is important to bear in mind that these neuroses are not to be con- 
sidered as separate diseases. It is rare indeed that one neurosis exists 
alone. Clinically we have to deal for the most part with combined neu- 
roses. 

NEUROSES OF MOTION 

I. IRRITATIVE STATES 

Varieties: — (a) Gastrospasm and peristaltic unrest; (b) cardio- 
spasm; (c) pylorospasm; (d) nervous eructation and vomiting. 

Gastrospasm and Peristaltic Unrest:— it is doubtful if neuroses 
of this type are ever primary. In the vast majority of cases the increase 
of motility is due to direct irritation of the mucosa by an excessive se- 
cretion of hydochloric acid, or to the presence of fermenting foods or 
gases, the result of indigestion. Pyloric stenosis, by preventing rapid 
emptying of the stomach may act as a cause of gastric spasm or muscular 
overaction. Nervous erethism is a predisposing cause. 

The simplest expression of increased stomach motility is rapid empty- 
ing of the stomach. In gastrospasm the whole stomach is firmly con- 
tracted; it is very uncommon. 

Peristaltic unrest consists in rhythmic contractions of the muscles 
of the stomach, running from the fundus toward the pylorus. If the 
abdominal wall is thin they are readily felt, and sometimes may be 
seen. The patient is conscious of this movement, which causes discom- 
fort, rumbling in the stomach, etc. It is often associated with pyloric 
stenosis or some displacement of the stomach. 

Cardiospasm: — In most cases this is due to hyperesthesia of the 
gastric mucosa, irritated by overproduction of HC1 or other mechanical 
or chemical irritants. It may be provoked by swallowing of air or the 
presence of gases, which set up muscular spasm. Inflation of the 
stomach may follow, known as pneumatosis. Passage of the stomach 
tube may cause spasm of the cardia and prevent its introduction. 

Structural conditions which may cause cardiac spasm are ulcer or 
erosion at or near the cardiac orifice, and cancer. 



508 NEUROSES OF MOTION 

Gas in the stomach may cause painful distention, difficulty of breath- 
ing, cardiac oppression, feeble pulse and headache. When the gas is 
passed the symptoms disappear. If the spasm persists a serious symp- 
tom is the difficulty of swallowing. Food may accumulate sometimes 
in an esophageal cul-de-sac. A diagnostic point of some value is, that 
a large stomach- tube is passed much easier than a smaller one; the 
opposite is true in stricture at this point. 

PylorOSpdStn: — The same causes as of cardiospasm. It may be 
induced by local irritants — hydrochloric acid in excess, hot or irritant 
foods, or the products of fermentation. Irritability of the nerves predisposes. 
Cancer, erosion or ulcer at or near the pylorus may cause spasm. 

Pyloric spasm occurring during digestion seriously interferes with 
emptying the stomach; there is food stagnation, maybe fermentation. 
Retention of food in the stomach may be detected by the stomach tube, 
by Ewald's salol test or Fleischer's iodine test. Prolonged spasm may 
result in organic stricture, gastric dilatation or gastroptosis. In associated 
cardiac and pyloric spasm gaseous distention is likely to be pronounced. 

Nervous Eructation and Vomiting :— Neurasthenic and hysteric 
conditions are the underlying factors in a large percentage of these cases. 
Eructation is often the result of air swallowing, especially in hysterics, 
though in many cases it is due to the gases of fermentation and then 
may be the result of any atonic form of indigestion, functional or organic. 
Nervous vomiting is frequently the symptom of disease remote from the 
stomach; it is characteristic of some diseases of the brain and its meninges, 
the spinal cord (locomotor ataxia), kidneys, liver, genital organs, and 
pregnancy. Psychic factors are particularly in evidence here; vomiting 
may be excited by disgusting sights, offensive odors and accompanying 
faintness. 

Nervous eructations are characterized by the expulsion of odorless 
and tasteless gas. It may occur remote from meals. It may be asso- 
ciated with spasms of the cardia or pylorus, and pneumatosis may com- 
plicate it. If there is regurgitation of acid contents this is called pyrosis 
or waterbrash. 

Nervous vomiting, though it usually follows meals, may occur at any 
time, or when the stomach is apparently empty. The appetite may 
be excellent and the character of the food or its quantity matters of 
indifference. Vomiting often comes without prodromal nausea and 
may be periodic. 

Treatment of Irritative Motor Neuroses— Neurasthenia demands an 
abundance of rest, the treatment being modified to meet the demands 
of the case; hysterics are very susceptible to suggestion, and this should 



NEUROSES OF MOTION 509 

be made free use of. Appropriate remedies to raise the tone of the 
patient and improve nutrition, such as strychnine, the arsenates and 
nuclein, may be indicated. 

The food should be easily digested and absolutely free from irrita- 
tion, therefore excluding condiments, pastries, sweets and other sub- 
stances which tend to undergo fermentative changes. Commence with 
a milk diet, which may be gradually enlarged. In spasmodic affec- 
tions of the pylorus it is better to give frequent meals and small ones 
because of the tendency to retention, stagnation and subsequent 
dilatation. 

Gas may be removed by the stomach tube; if this is passed with 
difficulty, relief Tnay be obtained by introducing a spray of menthol or 
cocaine through the tube to the point of spasm. Use a large tube. 
Galvanism is highly recommended. The Winternitz cold pack to the 
stomach is highly recommended in all the painful gastric neuroses. 

The medicinal indication is for antispasmodics and the best of 
these is hyoscyamine. This may be given in small repeated doses until 
relief is secured, and if there is accompanying vascular disequilibrium, 
as shown by pallor of the skin and cold extremities, it will be well 
to give glonoin to effect, maintaining the effect by the subsequent use 
of hyoscyamine. Strcyhnine in small doses will maintain the neces- 
sary vascular tension and nerve support. Hemmeter and others use 
the bromides in these cases, and the valerianates are also useful; the 
valerianate of strychnine is suggested. 

In cases associated with pain the gastric sedative combination of 
resorcin gr. 1-40, cocaine muriate gr. 1-100, atropine sulph. gr. 1-2500, 
delphinine gr. 1-1000, should be employed. This combination may 
be given every ten or fifteen minutes until relief is obtained. 

If there is gastric fermentation resort should be had to the sulpho- 
carbolates; frequently these may be combined with the subnitrate of 
bismuth to good advantage. This will not control purely nervous 
eructations, which demand psychic treatment of a vigorous character. 

If vomiting is troublesome the gastric sedative mixture above refer- 
red to will often be found effective. Oxalate of cerium is another good 
remedy, while small, frequently repeated doses of calomel should be 
given if there is associated intestinal sluggishness. A combination of 
cerium oxalate, bismuth subnitrate and calomel is good. Minute 
doses of phenol given in peppermint or chloroform water often 
check nervous vomiting. Where vomiting is so severe as to inter- 
fere seriously with nutrition it may be necessary to resort to rectal 
feeding. 



510 NEUROSES OF MOTION 

II. IN DEPRESSIVE STATES 

Insufficiency of the Card/a .'—Neurotic and psychic states pre- 
dispose to this condition. Here there is a paretic condition of the 
nerves supplied to muscles of the cardia. Whooping-cough is a fre- 
quent cause. 

The usual form is regurgitation of food. This may occur at any 
stage of digestion. 

A peculiar form is rumination or merycism, when food which comes 
up is rechewed and swallowed again. The patient experiences a pecul- 
iar satisfaction in this practice. 

Pyloric Insufficiency: — The general causes are defects in inner- 
vation, in rare cases ulceration and carcinoma. 

The food passes rapidly through the stomach and is unloaded into 
the duodenum before stomach digestion is complete. So long as the 
intestine and associated glands are able to do the additional work, 
there are no symptoms, but sooner or later, intestinal indigestion 
results. Pyloric insufficiency may be detected by inflating the stomach 
with gas; if the gas remains in the stomach and is not eructed the valve 
is intact, while if it disappears the inference is that it has passed over 
into the intestine. 

Gastric Atony: — May result from some nervous disorder, follow- 
ing acute or chronic disease which causes adynamia, or as a primary 
neurosis. Overloading the stomach, especially with fluids, causes mus- 
cular weakness and atonia; it is rather common in beer-drinkers. 
Ulcerative, spasmodic or stenotic conditions of the pylorus or obstruc- 
tive disease of the intestinal canal, may cause it. 

After eating there is a sense of fullness and oppression in the 
stomach, which persists till it begins to empty. There is temporary 
dilatation, which may become permanent. In mild cases the discom- 
fort lasts only for an hour or so; in the advanced it may persist from 
one meal to another. Accompanying symptoms are headache, eructa- 
tions of gas, possibly vomiting, and constipation. Fermentation is a 
result of food retention, and is likely to result in troublesome gas 
formation. 

A common, though not very reliable, method of testing gastric 
motility is by the salol test; this consists in administering a gram of 
salol by the mouth; not being readily absorbed by the gastric mucosa 
it does not appear in the urine until after it has reached the intestinal 
canal. Normally it appears in the urine as salicyluric acid within 45 
minutes to one hour after ingestion. 



SENSORY NEUROSES 511 

A simpler and more reliable method is the administration of water 
on an empty stomach, noting by percussion the descent of its lower 
border with increasing quantities of the fluid. Or by succussion the 
splashing of retained fluids may be detected, aided by the stethoscope 
placed over the epigastric region. Inflation with gas also serves to out- 
line the size and distensibility of the organ. Other methods of deter- 
mining this are by the use of Einhorn's gastrodiaphane, or by the x-ray, 
the walls of the stomach having been made opaque by the administra- 
tion of bismuth subnitrate. 

The Treatment of Depressive States .'—Neurasthenics and hys- 
terics should receive appropriate treatment. Diet should be ad- 
justed to the condition of the secretions. In many cases the HC1 is 
diminished but not always. Very bulky food and large quantities of 
fluid must be avoided. The food should be concentrated, very nutri- 
tious and not inclined to fermentation; sweets and wines forbidden. A 
slightly stimulating diet, unless contraindicated may be prescribed. 

Massage, faradization, the cold shower and sponge baths to arouse 
reaction, may be advisable. 

Benefit is derived from bitter tonics. Strychnine, quassin, capsicin 
and similar remedies will be found effective in appropriate cases, with 
berberine to contract the relaxed connective and juglandin to control 
the tendency to constipation and stimulate the protective forces of the 
liver. If there is defective secretion of HC1 this should be administered, 
one-half to one hour after meals, the bitter tonic being taken either 
with the food or directly before eating. Pepsin or other digestants are 
not required. 

SENSORY NEUROSES 

Hyperesthesia : — This is most common in nervous women, "run 
down" and irritable from overwork, nervous or psychic strain. Hyper- 
chlorhydria and errors of diet which produce it are exciting causes. 

Unpleasant sensations in the stomach are felt, fullness, burning, 
pain and throbbing (consciousness of aortic pulsation, especially in 
thin persons). These follow the ingestion of food and disappear at the 
end of gastric digestion. There are often headache, neuralgia, etc., 
sometimes vomiting, peculiarly erratic appetites, for things apparently 
indigestible which are eaten without discomfort. Urticarias following 
strawberries, shellfish, etc., are often the result of gastric hyperesthesia. 

Treatment should be addressed mainly to the underlying cause. 
Hyperchlorhydria should be treated along the lines hereafter described. 



512 SENSORY NEUROSES 

A hot water bag on the stomach during digestion often relieves distress. 
Sedatives are indicated as described for the Irritative Motor Neuroses. 
The "gastric sedative" combination is especially to be commended; 
while strychnine valerianate is the proper remedy to "take up the slack". 

Gastralgia; Gastrodynia; Neuralgia of the Stomach:— This com- 
mon and very painful neurosis is prone to appear in women, with 
menstrual disorders or at the menopause. Weakness, malaria, syphilis, 
anemia, hemorrhage or anything which undermines the strength may 
act as a predisposing cause; while exciting causes are nervous or mental 
strain, physical exhaustion and various gastric disturbances, but espe- 
cially hyperchlorhydria. The gastric crises of locomotor ataxia are 
closely allied. There seems to be no direct association between taking 
food and the attacks; they may come immediately after eating or when 
the stomach is empty. 

While there may be prodromal symptoms, headache, gastric dis- 
comfort or depression, in most cases the attacks come without warning. 
The pain is agonizing, extending through to the back, relieved by firm 
pressure upon the pit of the stomach or by hot drinks. The skin is 
bathed in cold, clammy sweat, the extremities are cold and clammy, the 
pulse rapid and feeble. The attack may last a few minutes, an hour, 
or more, and terminates with vomiting, the eructation of gas, or the 
passage of a large amount of nearly colorless urine. These attacks 
show a decided tendency to recur. 

Very often gallstone colic is mistaken for gastralgia, or one for the 
other. In both the pain is very severe and paroxysmal in type, but in 
gastralgia the pain is relieved by pressure and runs through to the 
back, while in biliary colic it is unrelieved by pressure, is seated more 
to the right and tends to run up into the shoulder blade; biliary colic 
is also usually followed by jaundice and the stone may be found in the 
stools. 

In gastric ulcer and carcinoma there is pain of an entirely different 
character, intimately associated with the process of digestion and easily 
diagnosed. 

In intestinal colic there is usually a history of ingestion of improper 
food; the pain is diffuse but centering around the umbilicus and there 
is a tense and tympanitic abdomen; pain is relieved somewhat by the 
passage of gas. 

Gastralgia is seldom if ever fatal. 

Treatment: — Undigested food in the stomach or bowels should 
be removed. An enema will unload the lower bowel and the stomach 
tube may be brought into requisition if that viscus seems distended. 



SENSORY NEUROSES 513 

Usually a number of small repeated doses of calomel, followed by a saline 
laxative, will prove sufficient. The sulphocarbolates should then be 
given to check any fermentative or putrefactive process, and put the 
canal in a thoroughly innocuous condition. A teaspoonful of sodium 
bicarbonate or 40 drops of chloroform, in a glass of water, will quickly 
relieve. 

In mild cases pain will often be relieved- by local applications of 
mustard, turpentine stupes, hot fomentations or the hot water bag. 
Severe cases may require resort to morphine hypodermically, but usually 
atropine alone will give relief. A granule of glonoin gr. 1-250, and 
one each of hyoscyamine gr. 1-250, and strychnine valerianate gr. 1-134, 
administered in hot peppermint water every fifteen minutes, will usually 
give prompt relief. The zinc and codeine tablet (containing zinc sul- 
phocarbolate gr. 1, codeine sulphate gr. 1-8, hyoscyamine amor. gr. 
1-500 and strychnine sulphate gr. 1-134) is an excellent preparation in 
these cases, the sulphocarbolate serving to check any tendency to fer- 
mentation. Good diffusible stimulants are aromatic spirit of ammonia, 
Hoffman's anodyne, and Jamaica ginger; these serve as household 
remedies and are often sufficient. Here, as in many other conditions, 
relief is usually obtained by arresting the vascular spasm and bringing 
the blood to the surface; hence the value of the combination of glonoin, 
hyoscyamine and strychnine. 

The subsequent treatment depends entirely upon the cause. Gen- 
erally speaking it should be reconstructive and corrective of any gastric 
or other associated trouble. 

Anorexia; LOSS of Appetite: — Loss of appetite occurs as a prodrome 
and a symptom of most acute diseases; also in many chronic ailments. 
Constipation, biliousness and other forms of intestinal autotoxemia, are 
often marked by poor appetite. As a pure neurosis it occurs, but not 
often, usually during neurasthenia or hysteria. Hemmeter notes that 
in these cases there is usually a reduction of HC1. 

Treatment must be directed to the underlying condition. The bitter 
tonics are most effective, taken in solution so as to act directly upon the 
gustatory nerve terminals. Quassin is generally satisfactory. Orexin 
has been shown to be effective. 

Appetite as a factor in digestion is not half appreciated. The studies 
of Pawlow have shown that digestion is dependent very largely upon 
psychic causes, much more perhaps than upon the direct stimulation of 
the gastric mucosa by the presence of food. In a normal person the odor 
of an appetizing meal or the appearance of a well garnished dish excites 
the flow not only of saliva but of the gastric secretions as well. If appetite 



514 SECRETORY NEUROSES 

is in abeyance the digestion must suffer. Where appetite and di- 
gestion are feeble, prepare the food in the most appetizing way possible. 
Hyperorexia; Bulimia; Excessive A ppetite:— Excessive appetite is 
one of the characteristic symptoms of diabetes mellitus. It occurs 
occasionally as a neurosis. Appetite is however "very various"; the 
growing boy or the healthy farm hand may be expected to take more 
interest in his food than a seamstress working in a city tenement. Allow 
for such differences. True hyperorexia may come soon after eating, 
and if food is not taken there may be headache, pallor, or cardiac palpi- 
tation. When no satiety follows eating the condition is called acoria. 

SECRETORY NEUROSES 

hyperchlorhydria; hyperacidity 

There are only two conditions in which there is an increase in the 
quantity of HC1 secreted by the stomach. The first we are now 
describing; the second is ulcer of the stomach. It may occur occasion- 
ally in other affections, as tabes and migraine, and in "acid gastritis," 
but not constantly. Unlike nearly ail other neuroses it is more com- 
mon in men than in women. It occurs much in the better classes of 
society — among brain workers — but it may occur in any class. It is 
very frequently described by the laity under the very comprehensive 
term of "heartburn." A rich proteid diet, with abundance of condi- 
ments and alcoholic or other stimulating drinks predisposes to it. 

The normal quantity of hydrochloric acid varies greatly in different 
individuals. Among the Japanese and other races which live largely 
upon cereals, with little meats, the secretion of HO is much smaller 
than among meat-eating nations. In this country the average is probably 
about o.r5 per cent. But some persons will secrete twice this percentage 
and suffer no discomfort. Furthermore, much depends upon the irri- 
tability of the individual stomach — as well as of the individual himself. 
In hyperchlorhydria the percentage is increased to twice or even four 
times the normal quantity. Americans are said to be a "nation of 
dyspeptics," and this is the form of dyspepsia from which most of them 
suffer; it is estimated that at least 25 per cent of the digestive ailments 
fall under this head. The gulping down of half masticated food, mixed 
with a heterogeneous mess of condiments, sauces, pastries and drinks, 
hot and cold, is peculiarly an American vice and plays the exciting part. 

This is not "poor digestion." Until some permanent change takes 
place in the stomach as a consequence of being bathed at frequent inter- 
vals in a highly irritating fluid, the digestion is good — abnormally good. 



SECRETORY NEUROSES 515 

There is a slight shortening of the period of starch digestion in the 
stomach, but otherwise the work is well done, and proteid is disposed 
of with great rapidity. 

The symptoms are referable to the irritation produced by the excess 
of HC1. The leading symptom is pain, which varies greatly in intensity, 
but is usually burning or gnawing, and gives a sensation of rawness in 
the epigastrium. There is usually tenderness over the stomach, diffuse, 
not well localized. The pain presents the following characteristics: 

1. It appears one to three hours after the meal, is most intense during 
the height of digestion and usually ceases when the stomach is emptied. 

2. It is relieved by taking alkalies or proteid food, as mi k, meat 
or egg. 

There are other symptoms of varying importance, which depend upon 
the degree of hyperesthesia of the mucosa. Thus, vomiting occurred 
in one-third of Hewes' cases; eructation of gas (usually odorless and 
tasteless) and regurgitation of acid fluid, consisting of the nearly digested 
meal, are common. 

In an irritable stomach the acid may se: up spasmodic conditions 
at either orifice, or more rarely of the entire organ; these add greatly 
to the distress, and if there is considerable spasm of the pylorus the food 
is not readily expelled into the duodenum, while as a result of the pro- 
longed contact the mucosa becomes irritated and finally inflamed, the 
organ dilated and its musculature at last atonic. In other words we are 
dealing with a mixed neurosis of secretion, motion and sensation, one 
which is very likely to terminate in gastric catarrh with dilatation. 

Constipation is a very constant symptom, due to pouring the very 
acid chyme into the duodenum and consequent prolongation of intestinal 
digestion. 

A test meal should be given and the contents withdrawn and examined. 
The Ewald-Boas consists of a dry roll or wheat bread (two ounces) and 
two cups of tea (unsweetened) or water. At the end of an hour the con- 
tents of the stomach is withdrawn and examined. The following test 
may be used to determine the amount of free hydrochloric acid: 

Dimethylamidoazobenzol test (Topfer's test): — Two or three drops of 
a 0.5 per cent alcoholic solution of this drug are added to the filtered 
solution withdrawn from the stomach, of which exactly 10 Cc has been 
taken. This turns the solution a bright red. Now we add, drop by 
drop, decinormal NaOH solution, shaking frequently. When the acid 
is completely neutralized the red fades out. To compute the percentage 
multiply the number of Cc. of the NaOH solution required to neutralize 
the acid by 0.00365, the quantity, expressed in grams, of HC1 in the acid 



5 i6 SECRETORY NEUROSES 

solution. This test is sufficiently accurate for all practical purposes. 
For phenolphthialein test for total acidity see elsewhere. 

Closely allied to hyperchlorhydria is gastrosuccorrhea (gastroxynsis) . 
In this condition there are recurring attacks of hypersecretion. These 
come when the stomach is empty, often at night, severe pain, nausea and 
vomiting of large quantities of acid gastric juice, which may be mixed 
with bile and contain mucus. There is intense thirst. There are the 
usual symptoms of shock — headache, pallor, cold skin and extremities, 
etc. The health in the intervals is usually good. 

Reichrnann's disease (Gastrosuccorrhea continua chronica) is another 
disease in which there is excessive HC1 secretion, a form of hyperchlo- 
rhydria. Here the stomach continues to secrete without intermission, 
even when fasting. Acid vomiting is frequent. 

Diagnosis: — Hyperchlorhydria is most likely to be confounded 
with gastric ulcer. In both there is an excessive secretion of HC1 
and it is highly probable that ulcer may result, at least sometimes, from 
the neurosis. In ulcer the pain appears when the acid flow begins, and 
is aggravated instead of relieved by the taking of food; it is also char- 
acterized by a sharply localized tenderness in the majority of cases and 
usually there is vomiting of blood. There is also a constant dull pain, 
passing through to the back. 

There is a form of acid gastritis, symptomatically almost identical 
with hyperchlorhydria, the treatment exactly the same. The main 
difference is that in acid gastritis the stomach washings contain mucus 
and epithelial debris suggestive of inflammatory action. It can readily 
be conceived that during the first stage of a low-grade inflammation of 
the mucosa the parenchymatous cells may be excited to increased secre- 
tion, to be followed later by destruction of glands or diminished activity. 
Boardman Reed gives especial prominence to acid gastritis and believes 
that many supposedly neurotic cases are really inflammatory. It is easy 
to see that an acid-bathed stomach may become later an inflamed one 
if the hypersecretion is not checked. 

The prognosis of hyperchlorhydria is good, though its complications 
may cause permanent trouble. 

Treatment: — Any depraved state of the general health should re- 
ceive appropriate treatment; but in many cases it is difficult to fix a 
neurotic basis. 

Diet is of the utmost importance and by its careful adjustment the 
case may in many cases be cured without other treatment, provided there 
is no very strong underlying neurotic diathesis. In some cases the 
nervous condition seems to depend rather upon the disorder of digestion 



SECRETORY NEUROSES 517 

than the reverse; at any rate, proper treatment of the stomach trouble 
will do more to effect a cure than in most other gastric neuroses. In diet- 
ing these patients keep in mind the following facts: 

1. That the digestion of proteids is unimpaired; indeed, it may be 
somewhat too active. Albumen enters into combination with HC1 
and thereby arrests, naturally, the overacidity. 

2. That the period of starch digestion is somewhat shortened on 
account of the rapid appearance of HC1 in the stomach, the conver- 
sion of carbohydrates taking place only in an alkaline medium. 

3. That stimulating foods of any kind, whether mechanically irri- 
tant, stimulating from heat, or from the presence of irritant volatile oils 
(condiments), or from a rich content of extractives (red meats), serve 
to increase the flow of HC1. 

The diet should contain considerable albuminous food, sufficient 
to combine with all the free acid, but this food should be as free as 
possible from irritant substances. We therefore exclude condiments, 
very hot drinks of all kinds, and reduce the amount of red meats to a 
minimum; regarding the use of meats there is, however, a difference of 
opinion, some physicians recommending their use, usually raw and minced 
since they enter into combination very readily with the free acid in the 
stomach. The objection to their use is that, while they give great tem- 
porary relief, they delay rather than aid permanent cure. Where it is 
agreeable to the patient milk is the best food for acute stages; it should 
be given in small amounts, about six ounces every two hours, warm not 
hot, and sipped slowly. The pain is usually relieved at once. To pre- 
vent curding as well as for the alkaline effect it is a good plan to add a 
little Vichy, lime water or soda. After the irritation has somewhat 
subsided in severe cases a little toasted bread, zwieback or cracker, in milk 
if preferred, may be taken. 

After the acute attack has subsided it is seldom necessary to lay down 
a rigid dietary, if general attention is given to the underlying principles. 
Since these attacks are likely to follow dietetic errors the patient should 
be given to understand the necessity of abstemiousness, of simplicity 
in the choice of food, of thorough mastication and avoidance of all stimu- 
lants. The meals should be small but frequent enough for relief. The 
following is a sample day's dietary as suggested by Stockton: At 
breakfast, a soft boiled egg, a dry stale roll and a bit of broiled bacon; 
in the middle of the forenoon a glass of hot milk; at noon zwieback and 
the warm milk; middle of the afternoon, a glass of milk; in the evening 
a substantial dinner, of fish, beef or mutton with vegetables, but no 
dessert. 



518 SECRETORY NEUROSES 

All acids disagree with these patients and for this reason the fresh 
acid fruits and vegetables such as strawberries, cherries, oranges, lemons, 
tomatoes etc., are likely to make trouble, setting up severe paroxysms of 
pain two hours or so after eating. Fruit juices and acid wines have a 
similar effect. On the other hand, fats and oils check the secretion of 
HO, and may be decidedly beneficial; an abundance of cream, butter, 
olive oil, etc., not only favorably influences the gastric condition but 
helps to improve the nutrition. 

Carbohydrates should be taken in accord with the digestive capacity 
of the patient. Large quantities are not only undigested in the stomach, 
but on account of the large quantity of acid chyme thrown into the duo- 
denum, its digestion is interfered with in the intestine. Take what can 
be used and no more. It may cause fermentation and gas formation 
in the stomach, in spite of the large amount of HC1; yeast fungi are 
nearly always present and act readily upon undigested starchy food. 

Medicinal Treatment: — The drugs of most general value in hyper- 
chlorhydria are the alkalies. These are given during the height of 
digestion to neutralize the excess of acid. Nearly every individual who 
suffers from " heartburn" has learned of the relief that can be secured 
from a dose of soda. There are few better remedies. It should be 
taken after meals, just before the inception of the expected pain. One 
half to one dram is the usual dose. It may be taken in milk, as already 
suggested, or in water. Calcined magnesia has the added advantage of 
relieving somewhat the accompanying constipation. Vichy or other 
alkaline waters serve the same purpose and have this advantage — they 
help to deplete purses which are too plethoric to appreciate the advan- 
tages of the cheaper remedies. 

With the alkali or alone the physician may also administer such gas- 
tric sedatives as bismuth subnitrate and cerium oxalate. 

The remedy which has the most decided effect upon secretion is atro- 
pine; this checks hypersecretion from the stomach, just as it does from 
other mucous surfaces. Sometimes this remedy has a remarkable in- 
fluence upon these cases, and it should certainly be given a trial in every 
severe case. Codeine, which relieves pain and modifies secretion, is not 
to be recommended. The pain is so readily relieved by proper diet and 
alkalies that resort to narcotics is not to be thought of, especially in 
neurotic patients. 

hypochlorhydria; sub acidity 

While a deficient secretion of HC1 is one of the characteristic symp- 
toms of chronic gastritis and carcinoma of the stomach, it also occurs 



SECRETORY NEUROSES 



5i9 



not infrequently as a neurosis. In the first-mentioned disease, however, 
the reduction in the quantity of acid is constant, while in the neurosis 
it usually varies; indeed, periods of subacidity may alternate with nor- 
mal or excessive secretion. Defective secretion causes no symptoms 
provided the motility of the stomach is good and it empties itself 
promptly; in such cases the work of digestion is taken up and com- 
pleted in the intestines. With defective motility, however, there is 
stagnation of food in the stomach, fermentation, gas formation, a sense 
of fullness, eructations and other symptoms of poor digestion. If there 
is much proteid food it decomposes and interferes with intestinal 
digestion, the patient passing foul-smelling stools and suffering from 
constipation, occasionally varied by diarrhea. Starch digestion is bet- 
ter than proteid digestion. If the condition persists nutrition is impaired. 

In gastritis the subacidity is more constant and the stomach wash- 
ings contain mucus and epithelial debris. 

Gastric cancer presents a picture hardly to be confused with neu- 
rotic subacidity. In cancer there is excess of lactic acid, absence of 
HC1 usually, pain some hours after eating, vomiting of blood, " coffee- 
ground" like in appearance, cachexia and emaciation, some fever, and 
the presence of a tumor. 

The prognosis of nervous subacidity is usually good. 

Tredtment: — In these cases the carbohydrates are most easily 
digested and should be quite largely depended upon, avoiding things 
which ferment easily, and bulk and liquids when there is a tendency 
to stagnation. Starch digestion may be aided by diastase and malt 
extracts, when they seem indicated. Proteids should be given in a 
form to stimulate gastric secretion; here finely chopped meats are 
indicated and the use of condiments is not only permissible but they 
may even be decidedly helpful. Watch the stools and do not give pro- 
teid enough to cause fetid discharges. HO after meals is indicated; 
pepsin is usually not required, since the quantity of pepsinogen secreted 
is generally sufficient, only acid being needed to convert it into an 
active form. In a few cases, however, the addition of a little pepsin 
seems to do good, whatever the theoretic indications. The hydrochloric 
acid should be taken in generous doses (20 to 30 drops of the dilute 
acid) in water through a glass tube. Take half an hour after eating. 
Papayotin is excellent in this class of cases. The bitter tonics are 
indicated. Quassin, taken in solution, or in granule form, dissolved 
in the mouth, is indicated here. Capsicin also acts nicely. If food 
stagnates, it may be necessary to resort to the stomach tube, as in 
chronic gastric catarrh (which see). 



520 GENERAL CONSIDERATIONS 

Achlorhydria; Achylia Gastrica:— In this neurosis there is an 
entire absence of hydrochloric acid from the gastric secretion. The 
only other conditions in which this occurs are carcinoma of the stomach 
and chronic gastric catarrh with atrophy of the gastric glands. This pro- 
duces no symptoms so long as the motility of the stomach is unimpaired 
and the intestines are able to do the additional work thrown upon 
them by the gastric insufficiency. The symptoms are those due to 
food stagnation in the stomach — gas formation, a sense of fullness, nausea 
and vomiting of a fermenting mass of undigested food. The discom- 
fort arises soon after taking food into the stomach, and is relieved by 
emptying the stomach, by vomiting or the tube. The fermentation and 
putrefaction of food inclines to the production of diarrhea from time 
to time. Headache, coated tongue, sallowness, nervousness and similar 
symptoms, characterize these atonic forms of indigestion. 

The treatment is essentially the same as of subacidity (hypochlorhyd- 
ria). Give food in small quantities, in as finely a chopped or com- 
minuted a form as possible, so that it may be reached by the intestinal 
juices and the ferments employed to the greatest degree possible. Hydro- 
chloric acid, pepsin and bitters should be used after meals. In some 
cases excellent results are obtained by the use of the vegetable proteid 
enzyme, papayotin. This has the advantage of acting in an alkaline 
as well as acid medium. 

VIII. DISEASES OF THE INTESTINES 

GENERAL CONSIDERATIONS 

The Feces: — Only of late is attention being given to routine ex- 
aminations of the feces. Visual inspection may detect parasites, 
tumor fragments, foreign bodies, concretions, blood, bile, pigment, 
fat, pus, mucus, and food residua. The shape of firm masses 
may be ribbon-like from outside pressure or pipe-stem from passage 
through a stricture, or scybalous from retention in pouches. Excess 
of fat gives a silvery appearance, or the fat may float on the surface of 
liquid stools. Mucus may appear as jelly masses, water or milk white, 
sago grains or mixed through the stools. Scybala may be streaked 
with blood or covered with pus. Dark stools are usually long retained. 
Alcoholic stools are white, putty-like. Blood exuded high up the small 
bowel appears as tarry masses, unless quickly passed from excited 
peristalsis. Gallstones and other bodies may be found on passing the 
fluidified feces through a sieve. The odor of the stools is an impor- 



INTESTINAL CATARRH; ENTERITIS. 521 

tant indication. An increase of the ordinary bad odor indicates absence 
of the antiseptic intestinal secretions or abnormal retention and decom- 
position. Iron and charcoal as well as bismuth blacken the stools; 
logwood imparts a peculiar reddish tint. 

By the microscope we may detect the small parasites and their eggs, 
and innumerable bacteria and food remnants. The degree of digestion 
of various elements is of import. Triple phosphates indicate reten- 
tion. Chemic examination detects bile pigment, ferments, fatty acids, 
blood, indol, etc. Bacterial tests supplement the microscopic. 

Physical Examination: — Inspection and inflation help in diagnosing 
local obstructions, and other phenomena. Palpation is an important 
aid. The patient lies on the back with the abdomen relaxed, though 
many times this must be aided by examination while lying on the face, 
as when heavy tumors retreat beyond reach. When the intestines arc 
distended with air or water displaced organs and neoplasms usually 
return to their normal locations. Contracted bands of intestines may 
be recognized, as well as dilated portions. Percussion detects fluid 
accumulations, free or circumscribed, as well as enlarged or displaced 
viscera, and gaseous or fecal collections. Auscultation has revealed 
chronic intestinal indigestion by the splashing when air and fluid are 
forced through a narrow like the ileocecal valve. A dilated colon may 
occasion similar sounds. Paralysis may be detected by cessation 
of the normal peristaltic sounds. Inflammation contributes friction 
sound, and auscultation during forced gaseous distension may reveal 
the location of obstructions. 

With the most careful use of these methods of physical examina- 
tion it is sometimes difficult to make a correct diagnosis, and especially 
to determine the presence and nature of masses that may be fecal or 
otherwise. The intermittent appearance of blood or pus in the stools 
with localized pain and tenderness sometimes signifies the presence of 
a hematoma or an abscess communicating with the bowel periodically. 

INTESTINAL CATARRH; ENTERITIS 

Intestinal catarrh, or enteritis, is an inflammation of the intestinal 
mucosa. It may be acute or chronic and the symptoms vary consider- 
ably according to the seat of the inflammation. In some cases the 
small bowel is most affected; in others the large bowel; while in others 
the entire intestinal tract may be involved — even the stomach occasion- 
ally partaking in the inflammatory reaction (gastro-enteritis). Dif- 
ferent names are given to the disease, according to its location. Thus 



522 ACUTE INTESTINAL CATARRH. 

we may have duodenitis, jejunitis, ileitis, typhlitis, colitis, sigmoiditis 
or proctitis; or we may have mixed forms, as ileo-colitis, etc. These 
will be discussed later. 

In both acute and chronic inflammation of the intestine there are 
primary and secondary forms; in the first case the bowel is the part pri- 
marily affected; in the second case the disease is dependent upon some 
affection of the body elsewhere. 

ACUTE INTESTINAL CATARRH 

This may occur at any age but is most common in children. The 
most common cause is the ingestion of food which is indigestible or 
tainted. Thus decomposing milk, meat, fish, etc., are particularly 
prone to cause an inflammatory reaction within the intestine, due to 
the evolution of the saprophytic bacteria and their poisons, the ptomains. 
Too large quantities of ordinarily digestible food, ice-cold drinks, impure 
water (even a mere change of drinking water), unripe fruits, foods 
which contain mechanical irritants and many drastic and poisonous 
remedial agents, such as croton oil, arsenic; lead, etc., act as causes. 
Variations of temperature in the summer months in some way predis- 
pose to the causation of the disease, probably through the vasomotor 
disturbance. It may also result from the production of poisonous 
substances within the body; thus it is well known that extensive burns 
frequently cause diarrhea and may even produce intestinal ulcers. The 
germs introduced into the intestinal tract, such as the colon bacilli, may 
also occasionally set up inflammatory diarrhea. Less common are the 
secondary ententes which may accompany debilitating diseases of the 
heart, lungs, liver and kidneys, or be associated with any of the severe 
infections. 

Pathology: — As already stated any portion of the intestinal tract 
may be affected, though the colon suffers most frequently. Osier says 
that "changes in the mucous membrane are not always visible," and 
that the three signs of catarrhal inflammation, redness, swelling and 
increased secretion, may all be absent post mortem. The tips of the 
valvulae conniventes are likely to be somewhat injected and there is 
some sticky mucus, but as a rule the mucosa is pale and anemic. The 
Peyer's patches and solitary follicles are usually prominent; the latter 
may present eroded areas in their centers, the so called follicular ulcers. 
In the more intense inflammations, as for instance in the severe toxic 
forms, there may be decided hyperemia and perhaps some loss of tis- 
sue, with extravasations of blood. 



ACUTE INTESTINAL CATARRH 523 

Symptoms: — The principal symptom, in the majority of cases, is 
diarrhea, but its intensity and even its presence depends not only on 
the severity of the attack but also upon the localization of the inflam- 
matory area. An attack usually comes on rather suddenly with more 
or less colicky pain in addition to the diarrhea. The stools vary in 
number; there may be but two or three in the twenty-four hours, or 
twenty or more. The first passages are usually fecal in consistency and 
odor, soon becoming mushy, and finally are entirely liquid. The color 
varies according to the amount of bile mixed with them; usually brown 
at first, later they become yellowish or grayish yellow. The reaction 
is acid and the discharges are irritating to the anal region. The pain 
varies greatly in intensity. In some cases the patient suffers only a 
slight inconvenience; in others it is paroxysmal, associated with nausea 
and possibly vomiting. As a rule there is little or no elevation of 
temperature. There may be more or less rumbling in the bowel due to 
the passage of gas and the presence of liquid stool. There is usually 
some tenderness in the abdomen. 

The symptoms vary according to the location of the disease. When 
the upper part of the bowel is mainly affected the patient suffers little 
if any from diarrhea; in this case digestion is most impaired and there 
is more or less undigested food in the fecal matter. The lower the 
area affected the greater the amount of diarrhea. If the rectum is the 
principal seat of inflammation there is likely to be most distressing 
tenesmus with a constant desire to go to stool. If the sigmoid is 
greatly inflamed the tenesmus is not quite so severe and backache may 
be very troublesome. With acute colitis there is more or less tender- 
ness over the entire colon. W r ith duodenitis there is often jaundice; 
this condition is, in fact, the cause of the common catarrhal jaundice. 
Tenderness in this region following a burn is always suspicious. Look 
out for duodenal ulcer. 

Help in the way of localization may be obtained by observing the 
stools. It should be remembered that the stools are formed into fecal 
masses in the large intestine. Liquid, formless stools point toward inflam- 
mation of this area. A greater percentage of food fragments is to be 
expected when the small intestine suffers. Mucus is present in practi- 
cally all cases of enteritis and is diagnostic. If it is intimately mixed 
with the stool, the upper portion of the intestine is at fault. If it comes 
out in strings and fragments with the fecal mass it is probable that the 
colon is inflamed; if it follows the stool after much straining, appearing 
as a glairy mass, probably showing some staining with blood, the 
patient has a proctitis. 



5 2 4 ACUTE INTESTINAL CATARRH 

Examination of the urine usually shows indican. The bacteria 
in the stools are very numerous. 

Prognosis: — Primary cases, when properly treated, usually recover 
promptly. The prognosis in secondary cases depends upon the nature 
and severity of the original disease. 

Treatment: — The first thing to be done in a case of this kind is 
to thoroughly clean out the digestive canal. It is absolutely essential 
that the fecal irritant be removed completely, and rapid and complete 
relief can not be expected without this. Commence with small doses 
of calomel, giving to an adult ordinarily J grain every hour or half hour 
until a grain has been taken. This not only acts as a cathartic but also 
quiets the stomach and stimulates the flow of bile, acting thus as an 
intestinal antiseptic and deodorant. Within an hour after the last dose 
of calomel give the effervescent magnesium sulphate (saline laxative) 
in one or two teaspoonful doses, repeating every two hours till stools 
are odorless. In many cases it is also necessary to wash out the lower 
bowel with enemata or colonic tube. Where the inflammation is seated 
in the lower bowel and the stools are very foul this is generally neces- 
sary, and nearly always so in very young children with severe symp- 
toms. If vomiting is severe it may be a good plan to wash out the 
stomach also. If there is severe tenesmus small doses of codeine 
(1-12 grain to an adult) may be administered with the calomel; opiates 
may be needed — often however the spasm is better relieved with 
atropine or hyoscyamine — especially if the skin is cold and pale. As 
soon as the bowels begin to act freely commence with the sulphocar- 
bolates, using ordinarily the zinc salt; one to five grains may be given 
every two hours to an adult. With an irritable stomach the compound 
tablet of the sulphocarbolates, the "intestinal antiseptics," may be 
better tolerated; a five grain tablet every two or three hours is usually 
sufficient. Bismuth subnitrate may profitably be used at the same 
time as the sulphocarbolates, as it has a desirable local action upon the 
inflamed bowel and is slightly astringent. 

If the inflammation is in the lower bowel and tenesmus severe, local 
applications may be made. Thus, irrigations with tannic acid, i to 1 
dram to the quart, or with nitrate of silver, 5 grains to the quart, may 
be used. They should be retained a few minutes if possible. Solu- 
tions of boric acid, common salt, salicylic acid, etc., answer practically 
the same purpose. Clean out the lower bowel before using medicated 
injections. 

During an acute attack stop all food, commencing when it has sub- 
sided with mildest broths and gruels. Give no cold drinks, but let 



CHRONIC INTESTINAL CATARRH 525 

the palient sip warm drinks — as fennel or chamomile tea. Keep the 
abdomen warm with hot flannels, hot water bag or other hot applications. 
Absolute quiet — patient on his back in bed. Let the extremities be kept 
warm. 

CHRONIC INTESTINAL CATARRH 

Definition: — This is a chronic inflammation of the mucous mem- 
brane, giving rise to various symptoms, according to its localization. 

Etiology: — Chronic enteritis may result from a succession of acute 
attacks of the character just described. Prolonged and persistent abuse 
of the digestive function may produce it, just as it does chronic inflam- 
mation of the stomach — indeed it may follow chronic gastritis, the intesti- 
nal inflammation resulting from persistent bowel overwork, due to im- 
proper care or feeding. The disease may be primary or secondary. 
Secondary forms accompany diseases of the heart, lungs, liver and kid- 
neys, and diabetes. Intestinal parasites, worms, etc., may cause second- 
ary inflammation of the mucosa. 

Pathology: — The affected portion of the mucous membrane has a 
reddish brown or grayish color, the vessels are much distended and 
curved and twisted; the surface of the mucous membrane is covered with 
tenacious, transparent mucus. The membrane is usually thickened, 
sometimes very much so, and this may cause stenosis. In advanced 
cases the intestinal mucous membrane may be atrophied, as in the similar 
disease of the stomach. Often there is more or less extensive ulceration, 
especially affecting the follicles. Occasionally, instead of appearing 
as above described, the mucous membrane has a blackish or slate color 
with black dots at the top of the villi and also around or in the follicles. 
The latter gives it the so-called " shaved-beard " appearance. The 
inflammation, together with ulceration increases the amount of fluid in 
the intestine. This may be bloody or purulent, depending upon the 
nature and extent of the inflammatory process. 

Symptoms: — As in the acute form of the disease the symptoms depend 
largely upon the portion of the bowel affected; if it is localized in the 
small intestine the main symptoms are those of indigestion; if in the large 
intestine, diarrhea. The disease may exist for some time without caus- 
ing subjective symptoms. Usually however there is more or less dis- 
comfort and a tendency to the formation of gas. This discomfort usually 
appears several hours after the ingestion of food, or if there is diarrhea 
shortly before the evacuations. The indigestion is shown by borbor- 
gymus, bloating, the passing of flatus and other annoying symptoms 



526 CHRONIC INTESTINAL CATARRH. 

of this character. This gas formation may also give rise to various 
disagreeable symptoms due to the pressure which it exerts, such as 
asthma, palpitation of the heart, etc. Belching or passing of wind gives 
some relief. If the indigestion is severe the patient suffers from innu- 
trition and this is particularly the case when there is an associated catarrh 
of the stomach. He loses weight, becomes weak, irritable in temper, 
suffers from cold extremities, headaches, anorexia, etc. These symp- 
toms are in all probability due to intestinal autotoxemia. The symptoms 
above described are most characteristic of catarrh of the upper intes- 
tine. In such cases the tendency is to constipation but this often alter- 
nates with attacks of diarrhea due to the fact that the accumulating fecal 
matter is very prone to undergo decomposition, thereby becoming 
an irritant of the bowel and setting up diarrhea. These attacks of 
diarrhea are followed again by constipation. 

When the inflammation is mainly limited to the lower bowel the 
principal symptom is diarrhea. Usually there are a number of passages, 
from one or two to six or eight daily; these may occur in the morning 
only. The character of the stools varies greatly. Usually there is some 
undigested food and almost invariably there is mucus; in fact the presence 
of mucus is characteristic of enteritis. The localization of the process 
may often be determined by the degree of admixture of the mucus in the 
stool, as described in the preceding article. The presence of ulceration 
is shown by pus and blood. Usually the stool will be somewhat blood- 
streaked from eroded vessels, especially if the inflammation is well down 
in the bowels. The more frequent and painful the stools the lower 
down in the intestine is the disease; in proctitis, tenesmus is trouble- 
some. 

Diagnosis: — This disease is usually easy of diagnosis. When how- 
ever, the process is high up in the small intestine there is considerable 
likelihood that the trouble will be ascribed to stomach disease — espe- 
cially if there is a prior history of gastric catarrh. Examination of the 
stomach contents and of the stools will usually clear up the diagnosis. 

Mucomembranous enteritis is a disease of nervous women, char- 
acterized by the passage of large quantities of mucus with paroxysms 
of pain. In this disease there is no pus or blood in the stool and the 
patient has a neurotic history. With a little care there should be no 
trouble in diagnosing ordinary cases. 

Prognosis: — Chronic catarrh of the intestine is a persistent disease 
and in the aged, debilitated or very young, it may be fatal. It has a ten- 
dency to hang on for months and even years, though when treated early 
and intelligently cure is possible in a majority of cases. 



CHRONIC INTESTINAL CATARRH 527 

TreBfment: — Hygiene and diet are of the utmost importance. 
The patient should adjust his life and his habits to his condition. He 
should live out of doors as much as possible, take mild exercise of a 
character which does not exhaust, clothe himself warmly keeping the 
extremities and abdomen at an equable temperature — in fact he should 
avoid all extremes and lead a sane, temperate life. The diet should be 
adjusted to the condition of the gastric chemistry as revealed by examin- 
ation of the stomach contents after a test meal. It is important that 
enough food should be given to maintain the nutrition; and it is equally 
important that the food should be of a character that the patient can 
utilize. Usually eggs, lean meats, bread, butter, mashed or baked po- 
tatoes, rice, cream, etc., may be taken without difficulty. If there is 
intestinal indigestion foods should be used that are largely digested in the 
stomach and it may be necessary to add an artificial digestant, such as 
pancreatin or papayotin. If there is constipation the free use of fruits, 
vegetables and the more easily assimilated fats is advisable. If there 
is diarrhea the patient should avoid the laxative fruits, the various wines 
and mineral waters and the more laxative vegetables such as cabbage, 
and the like. After all the patient must be in the matter of digestion 
something of a law to himself. The diet must be simple. Let there 
be no course dinners, no rich sauces, gravies nor pastries, no extensive 
admixture of different articles of diet at the same meal. 

As already stated the artificial digestants may be needed. If stomach 
digestion is weak the patient may require hydrochloric acid, pepsin, 
papayotin, or possibly qiiassin as a gastric stimulant. If the pancreatic 
function is not properly performed pancreatin may be needed. But 
probably of the greatest importance is regulation of the bowels. If the 
patient takes no food which is irritant and does not permit irritant sub- 
stances to be manufactured in the intestine, which add to and perpetuate 
the catarrhal condition of the intestine, then the chance for rapid recovery 
is good. As far as possible, the bowels should be regulated by the diet, 
but it is practically always necessary to supplement this by suitable 
medicinal treatment. If there is a tendency to fecal accumulation or 
to putrefactive changes, an occasional " cleaning out" with calomel in 
small repeated doses, followed by effervescing magnesium sulphate, is 
advisable. In many cases the calomel and saline purge may be repeated 
once or twice a week with decided benefit. Usually, however, after a 
thorough cleaning out the action of the bowels may be maintained by a 
daily morning dose of the saline. In Europe rich patients go to Spas and 
drink the natural purgative water, and these are certainly very effective; 
but just as good effects can be secured in the average case at a minimal 



528 CHOLERA INFANTUM. 

expense by the use of the saline. The ordinary purgative pills are not 
to be recommended; they are bowel irritants and their tendency is to 
increase rather than alleviate the inflammation. As supplementary, 
however, to the saline, when this does not prove sufficiently active, we 
would suggest the use of small doses of podophyllin or juglandin. The 
bile acids (bilein), by supplementing the natural secretions of the liver and 
stimulating the hepatic functions undoubtedly do great good in this class 
of cases. Indeed it is of the utmost importance that the work of the 
liver should be kept up to par, since here we are dealing with a depraved 
condition of the intestinal tract inevitably resulting in the formation 
of poisons which the liver must take care of. Emetine for this reason 
is also a valuable remedy. Intestinal antiseptics are also indicated, 
especially in cases associated with diarrhea or with putrid stools. The 
best form of administration is the compound sulphocarbolates. Of 
remedies acting directly upon the inflamed mucosa bismuth is one 
of the best; the subgallate may be given both for its local and astringent 
effect. Nitrate of silver given in keratin coated pills so as to pass un- 
changed into the intestine has also been recommended. One-fourth 
grain is the usual dose. 

When the seat of disease is accessible from the lower end of the 
bowel suitable irrigation . or topical application should be employed. 
Nitrate of silver in solution may be used as recommended in the pre- 
ceding article. 

Daily cleansing with normal salt solution is good in colonic inflam- 
mations. Sometimes a one per cent alum solution does good, while creo- 
lin, salicylic acid, boric acid, and protargol, argyrol and other silver salts 
will naturally suggest themselves as valuable in some cases. Whenever 
a local application is to be made to the bowel remember that it must be 
first cleaned out with enemas or the long colonic tube. Whatever you 
do, do thoroughly. Persistence is absolutely necessary, for this is an 
essentially chronic disease and cannot be cured by helter-skelter, inter- 
mittent or careless medication, 

CHOLERA INFANTUM, 

Definition: — Cholera infantum is an intense intoxication of the 
intestinal tract in children, probably of bacterial origin, and characterized 
by intense vomiting and the passage of abundant watery stools, great 
prostration, rapid wasting and a tendency to early fatal issue. 

Etiology: — Cholera infantum occurs almost exclusively in milk-fed, 
bottle-raised babies, under two years of age. While the recent studies 



CHOLERA INFANTUM 529 

of Duval and Bassett point to the probability of the specific action of 
a microorganism, there can be little question that the poisons bred in 
infected milk are mainly responsible for its occurrence. Poor hygienic 
conditions predispose to it. It is a disease of the summer months. 

Pathology: — There are no very marked morbid changes in the bowel 
to be found after death. There are some evidences of a catarrhal process 
in the mucous membrane of the stomach and bowels, especially of the 
latter; there may be ulceration of the intestinal glands. The symptoms 
evidently depend largely upon the profoundly depressing effect of the 
toxins upon the central nervous system, which causes paresis of the in- 
testinal wall and as a consequence free leakage of fluid into the bowels. 
There is some cloudy swelling with other evidences of degeneration of the 
cells of the liver and other large glands and important organs of the body. 
Symptoms: — The disease may be preceded by mild diarrheal symp- 
toms, with pain and restlessness; but it generally commences abruptly. 
In its symptomatology it closely resembles Asiatic cholera. There is 
from the start great prostration attended by nausea, vomiting, purging, 
and high fever. The little one first throws up any food that may be in 
the stomach, then ejects mucus, bile and large quantities of serum. The 
discharges from the bowels are at first fecal in character, and acid in 
reaction but soon become watery, alkaline, greenish in color and have 
a stale, musty odor. They are very frequent and very profuse. The 
water drawn from the body is enormous in quantity; it goes through 
the diapers and may even soak through the bed-clothing. As this loss of 
fluid goes on the child rapidly loses in weight and in a few hours the 
rotundity of the form is lost, the fontanels become depressed, the features 
sharpened, the abdomen sinks and the surface of the body is pale and 
cold. The little patient rapidly passes into a semicomatose condition, from 
which it seldom revives, lies with eyes partially , open, ceases crying and 
only moans. Sometimes death is preceded by convulsions; or the child 
may pass into a hydrocephaloid condition, with retraction of the head. 
The rectal temperature may be very high (io6°F or more) while the sur- 
face of the body is cold. "When recovery is to occur the stools gradually 
become less frequent, and more fecal in character and the vomiting ceases. 
Convalescence is slow. 

Diagnosis: — The symptoms of cholera infantum are characteristic 
and the disease can hardly be mistaken for anything else. The profuse 
watery stools, the great prostration and the rapid wasting make up a 
symptom-picture to be found in no other disease except Asiatic cholera. 
Nevertheless some physicians have erroneously applied the term " cholera 
infantum" to cases of gastroenteritis. 



530 CHOLERA INFANTUM 

Prognosis: — This disease is very fatal. Most of these little patients 
die, fully 90 per cent of those less than six months of age. 

TteBtment; — Cholera infantum is usually a preventable disease. 
Indeed the teaching of the medical profession concerning the importance 
of cleanliness and the most scrupulous care in the preparation and 
administration of food has here borne fruit; the disease is now 
uncommon. 

At the beginning of an attack of infantile diarrhea of any kind, food 
should be immediately stopped and not resumed for twenty-four hours 
at least. Milk is absolutely forbidden. When there is commencing tol- 
erance for food a little barley water,' meat juice or light broth may be 
given tentatively. If, however, the case develops into one of true cholera 
infantum it is useless to try to give any food. 

The entire intestinal tract should at once be cleaned out, the lower 
bowel by enemas, or a soft rubber catheter used as a colonic tube. The 
stomach may be emptied in a similar way if vomiting is troublesome, as 
it nearly always is. If the case is seen while there is still some gastric 
tolerance small doses of calomel may be given, say 1-20 grain every half 
hour for five or six doses, following with saline laxative or rhubarb, 
with sulpho-carbolates, as later directed. Employ, also, lavage, gas- 
tric and intestinal, to completely clear the digestive tract. In using 
enemata it is a good plan to use normal saline solution, leaving a small 
amount for absorption, with the hope of replacing somewhat the large 
amount of food withdrawn into the bowel from the tissues. A small 
amount of tannic acid may also be added to the injection, both for its 
astringent effect and to neutralize the alkalinity of the stool. The sul- 
phocarbolates may also be added to the injected fluid. In some cases 
if loss of body fluids is very great, subcutaneous injections of the salt 
solution are advisable. 

Atropine is the best remedy when the stomach can retain noth- 
ing; this maybe given hypodermatically in doses of gr. 1-1500 to 1-500, 
repeating sufficiently often to get and maintain the physiological action. 
Morphine is generally advised, and while it may possibly be of service 
early it certainly is contraindicated in the later stages when the patient 
becomes semicomatose; it is doubtful if it is ever indicated. If given 
at all it should be in doses of gr. 1-100, to restrain excited peristalsis. 
Narcotism is readily induced and very fatal. To maintain the strength 
and restore the tension to the paretic vessels and tone up the intestinal 
muscle strychnine is of the utmost value, though in young children 
brucine is often to be preferred. Either of these alkaloids may be given 
hypodermatically if the stomach will not tolerate them. Intestinal anti- 



CHOLERA INFANTUM 531 

sepsis is of value, but the slight tolerance of the stomach for drugs makes 
it difficult. However, copper arsenite may usually be retained, if given 
in solution and in sufficient dilution; 1-3,000 to 1-1,000 of a grain may be 
given every ten minutes to half hour; after vomiting has ceased and the 
stomach has become sufficiently tolerant give zinc sulphocarbolate in J 
to 2 -grain doses every hour. 

The advice is usually given to administer stimulants in the form of 
iced brandy or champagne. More effective than these and less likely 
to do harm are small doses of glonoin, which, with strychnine, strengthens 
the heart and brings the blood to the surface, where it may be kept by 
the judicious use of atropine. If fever is high aconitine, fortified by 
cactin or digitalin should always be used. Pain may be relieved by 
Waugh's anodyne for infants. 

Local applications such as the spice poultice, are usually employed, 
though hot dry flannels answer the same purpose. The limbs should be 
kept warm, and where the entire surface of the body is cold the hot pack 
may serve to bring the blood to the skin. 

Under the usual treatment, as stated above, about 90 per cent may 
be expected to die. The writer will take the risk of being set down a 
braggart by stating here his conviction that the physician who loses a 
case of this sort is responsible for the death. Begin with the first loose 
or fetid stool from a child in its second summer; give at once calomel gr. 
1-20 every half hour if nausea or vomiting is present, continuing till this 
ceases or for six doses; then proceed with the alkaline syrup of rhubarb 
to which has been added sodium sulphocarbolate 10 grains to the ounce. 
Of this give a teaspoonful every two hours until the stools are healthy. 
If in a few hours there is not a change for the better, or immediately if 
the symptoms are choleraic, begin giving chemically pure zinc sulpho- 
carbolate, from gr. 1-6 to grs. 2 every hour until the danger is past. Do 
not w r orry over the child's inability to retain medicine — this will settle 
the stomach. If peristalsis and vomiting are excessive give a full hypo- 
dermic of atropine to sedate the vagus — it will do it. If the zinc is per- 
sistently vomited it is impure. 

This is the treatment of cholera infantum. Under it you should not 
lose a patient. Not 90 per cent, and not 1 per cent. The writer has 
thus treated all cases coming to him since 1880 and has not lost one 
solitary case. But when he says chemically pure zinc sulphocarbolates 
he means exactly that and nothing else. When the writer was lecturing 
on this topic to his class, one of the students said: "Well, we arc to have 
our first death from cholera infantum." " Indeed, and what is that?" 
"A child at the dispensary clinic, which has been treated under your 



532 INFANTILE DIARRHEA; ENTERITIS IN CHILDREN. 

system, but the child was too far gone and had too little vitality when it 
was first brought to us." This seemed sad, and I asked if it had been 
treated with zinc sulphocarbolate. The reply was, "Yes" — and then the 
student corrected herself and said — "Salol." Oh! We gently but 
firmly insisted that salol was not sulphocarbolate, and the latter was 
substituted. Needless to say that the patient recovered. It is not a 
question of the principle of intestinal antisepsis, but of the specific agent 
employed to secure it, and our 27 years' experience has firmly convinced 
us that in cholera infantum the one effective remedy is zinc sulphocar- 
bolate. Can we be blamed for feeling injured, when people assume 
that this means any intestinal antiseptic in any dose and manner, and 
as calomel is a good member of this class the old and tried and found 
wanting methods are, the same as those we advocate, and our story is a 
tale that is told and not worth again hearing? If our readers desire 
to test our method, test it and not something else. 

See to the hygiene of the premises sedulously. Change absolutely 
the food so as to starve out all microbes — dropping milk absolutely and 
using first barley broth or rice water, and from that go to pure, fresh, 
sound fruit juices. After a week of each, return to meat broths, or the 
predigested foods. 

After the choleraic stage has passed we will face a stage of intestinal 
inflammation, and this requires the treatment of enteritis. 

INFANTILE DIARRHEA; ENTERITIS IN CHILDREN 

Etiology: — This is a very common disease of infants, especially 
between the ages of six months and two years. While it is not infre- 
quent in breast-fed babies, owing to improper surroundings or personal 
hygiene, or as a result of too frequent or irregular nursing or a poor 
quality of breast milk, in most cases it occurs in bottle-fed babies. The 
predisposing causes are high temperature and improper food. It is a 
disease of the summer months. The summer heat not only depresses 
the sensitive nervous system of the child and upsets the vascular equi- 
librium but also favors the decomposition of food products. Milk, the 
principal food of young children, readily undergoes dangerous putre- 
factive changes, which makes it dangerous unless great care is taken 
in its preparation and preservation. Unclean utensils and the long- 
tube milk bottle have been responsible for many deaths. Nearly all 
cases of summer complaint in children are undoubtedly milk toxemias. 
In older children unripe fruit and other indigestible food may be re- 
ponsible for the trouble* 



INFANTILE DIARRHEA; ENTERITIS IN CHILDREN 533 

Duval and Bassett have found the bacillus dysenteriae of Shiga in 
many cases of this disease and it is probable that it is specific in some 
cases at least. 

Pathology: — There are no distinctive morbid changes, aside from 
a slight hyperemia, or a slight catarrhal inflammation. 

Symptoms: — The simpler form of the disease, known as acute dyspeptic 
diarrhea is due simply to overloading the stomach or improper food. 
The symptoms, however, are often out of proportion to the cause. They 
may appear gradually, preceded by fretfulness and loss of appetite, or 
come on suddenly, often in the night. There is usually nausea, vomit- 
ing and diarrhea with colicky pains. In rare cases there may be con- 
vulsions, while the temperature may go up rapidly and be high — possibly 
104 to 105. The stools are numerous, at first feculent, and containing 
casein and fragments of undigested food, gray or yellow in color; later 
they are thin and acid — or very offensive if there is decomposition of 
proteids. Mild cases under proper treatment recover within a few days, 
or as soon as the bowels have been thoroughly cleaned out. 

In entero-colitis the early symptoms are much the same, but the sym- 
toms more pronounced, the depression greater, the pain more severe. 
If the lower bowel is most affected, as is quite likely to be the case, there 
is more tenesmus, the stools are more frequent, and they often contain 
mucus and are blood stained. The abdomen is distended and tympan- 
itic along the colon, fever is present and contsant, and there is a distinct 
tendency for the disease to become subacute or chronic. This form 
of the disease is distinctly a toxemia and carries off many children in 
the summer months. 

Prognosis: — Good in the dyspeptic cases and usually good in entero- 
colitis if treatment is prompt and intelligent. In some of the cases, 
however, the toxemia is intense and carries off the patient in a few days, 
while in others it assumes a chronic form and after six weeks or so usually 
results in the patient's death. 

Diagnosis: — The differential diagnosis between the dyspeptic and 
inflammatory forms has already been pointed out. The ordinary sum- 
mer diarrheas are often confused with cholera infantum. In the last 
named disease the great thirst, the profuse watery discharges, the pro- 
found prostration with supervening collapse symptoms and the rapid 
wasting, are quite characteristic. 

Treatment: — Summer diarrhea is a preventable disease. If proper 
attention is given to the child's food and the utmost cleanliness is exer- 
cised in its preparation, preservation and administration, very few cases 
of the disease will occur. Especially is this necessary in giving milk, 



534 INFANTILE DIARRHEA; ENTERITIS IN CHILDREN 

which is particularly prone to decomposition. If the supply is ques- 
tionable it should be pasteurized or sterilized. All utensils should be 
kept scrupulously clean. The bottle should be carefully washed and 
scalded after every feeding, the rubber nipples carefully scrubbed and 
kept in soda water between feedings. The child should be frequently 
bathed and the clothing adapted to the changes of temperature. 

The first thing in treating an attack of summer diarrhea, whether 
dyspeptic or inflammatory, is to thoroughly clean out the entire digestive 
tract and put it at rest. If there is food in the stomach it may be washed 
out with an ordinary catheter used as a stomach tube, or in older children 
by the administration of a simple emetic — even warm water or. tickling 
the throat with the fingers being sufficient in some cases. The lower 
bowel should be cleaned out by enemas or colonic irrigation. To assure 
the complete emptying of the intestinal tract the child should then be 
given several small doses of calomel (1-20 to 1-10 grain) at half hour or 
hour intervals, followed by a dose of castor oil or effervescing magnesium 
sulphate, which can be sweetened and acidulated with a little lemon 
juice to make an agreeable drink. If there is considerable prostration 
give small doses of brucine and if the skin is cold and pallid bring the 
blood to the surface with small doses of atropine (1-500 grain) repeated 
to physiological effect. Most cases require some intestinal antiseptic 
to check fermentation and putrefaction; zinc sulphocarbolate in J to 1- 
grain doses meets the indications, though in older children the compound 
sulphocarbolates acts better in some cases. Dr. Waugh has vividly 
described the marvelous changes which result from the administration 
of these salts in summer diarrheas. Copper arsenite, in 1-1000 grain 
doses, is another remedy which acts admirably in summer diarrhea, 
especially in duodenal troubles. If vomiting is very troublesome bismuth 
is an admirable remedy; it may be given with the calomel, which is one 
of our best gastric sedatives when given in small doses; a fraction of a 
drop of creosote in peppermint water is also good. Nuclein always useful. 

Insist upon absolute rest of the entire digestive canal — and that 
means abstention from food. During the first twenty-four to forty- 
eight hours the baby needs nothing to eat. Absolutely forbid all milk 
— impress upon the parents that it is little better than a poison. A little 
boiled water given at frequent intervals, to which two or three drops 
of brandy may be added if there is much depression, is all that is needed. 
But if you are impelled to give some substitute for food a little barley 
water or egg albumen water will serve, and as the acuteness of the attack 
begins to subside a little Valentine's beef juice or bovinine. Return 
very slowly to the regular diet, and leave the milk to the last. 



PHLEGMONOUS ENTERITIS 535 

In acute inflammation of the lower intestinal tract local treatment 
is demanded. Irrigate thoroughly with normal salt solution or weak 
boric acid solution. If there is much mucus a weak (1 per cent) tannic 
acid solution may be used, and nitrate of silver in the same strength if 
the disease shows a tendency to linger. Tenesmus may be relieved with 
injections of starch water to which a little opium, or better codeine, has 
been added. 

CELIAC DISEASE 

This disease, also know as diarrhea alba, diarrhea chylosa, is ap- 
plied to a subacute intestinal catarrh, occurring principally in children, 
and characterized by copious, frothy, pasty or gruel-like stools, which 
often are extremely offensive. The abdomen is distended but soft. The 
child becomes anemic and emaciation and loss of strength are progres- 
sive. There is usually fever. The etiology is obscure, though the fil- 
iaria sanguinis hominis has been found in the stool. Ulcers have been 
found in the intestine but the pathology is not known. The disease 
usually terminates fatally. 

The treatment should be along the same lines already outlined in 
the treatment of summer diarrhea, i. e., thorough cleaning out of the 
intestinal tract, the use of intestinal antiseptics, such as the sulphocarbo- 
lates, vascular tensors and stimulants, such as strychnine arsenate, cell 
vitalizers, such as nuclein, etc, 

PHLEGMONOUS ENTERITIS 

Definition: — This is a suppurative inflammation of the mucous 
membrane of the intestine. 

Etiology: — This is a very rare disease and usually occurs as second- 
ary to a purulent process elsewhere or associated with septicopyemia. 
It may result from intussusception or strangulation or complicate exan- 
themata. 

Pathology: — Abscess formation is most frequent in the duodenum. 
The purulent process is the same as such a process elsewhere. 

Symptoms: — The symptoms are practically the same as those of 
septic peritonitis, i. e., severe pain, tenderness, tympanites and tenesmus. 
There is vomiting and high fever. Constipation is present. 

Prognosis: — The disease usually terminates fatally. 

Treatment is in the main surgical, medicinal measures being ad- 
dressed mainly to the relief of symptoms. 



536 CHOLERA MORBUS; CHOLERA NOSTRAS 

SPRUE AND PSILOSIS 

This is described by Manson as "an insidious, chronic, remitting 
inflammation of the whole or a part of the mucous membrane of the 
alimentary canal, occurring principally in Europeans who are residing 
or have resided in tropical or subtropical climates." It is characterized 
by inflammation and often by erosion or ulceration of the mucosa anywhere 
from mouth to anus. The oral cavity may be eroded or ulcerated and 
there may be flatulent dyspepsia; pale, frothy, fermenting stools; a dis- 
tended abdomen; anemia and wasting. The disease is slowly progres- 
sive and there is a tendency to relapses, also to atrophy of the mucosa. 
It is usually fatal, unless the progress of the disease is arrested by early 
and appropriate treatment. The treatment is symptomatic. 

CHOLERA MORBUS; CHOLERA NOSTRAS 

Definition: — This is an acute inflammation of the mucous mem- 
brane of the digestive tract presenting symptoms of acute intoxication 
and resembling in some respects Asiatic cholera. 

Etiology: — This is a disease of the heated season, and while it may 
attack persons of any age young adults are most affected. When it 
occurs in children under two years of age it is known as "cholera infan- 
tum" (which see, page 528). Poor hygiene and sanitation are predisposing 
causes but errors of diet, unripe fruit, decomposing food, etc., are 
directly responsible for the attacks. 

Pdthology: — The morbid anatomy is essentially the same as that 
of an acute enteritis, though the entire digestive tract may give 
evidences of inflammatory reaction. In some fatal cases no lesions 
have been found post mortem. 

Symptoms: — The disease usually commences suddenly, often in the 
night, though the onset may be preceded by malaise, loss of appetite 
and nausea. There is at first pain in the abdomen, nausea and severe 
and repeated vomiting. After the normal contents of the stomach have 
been ejected the^vomitus becomes watery and bile stained. Purging 
soon ensues and accompanies the vomiting. The passages are very 
numerous and accompanied with severe abdominal pain. The stools 
are at first feculent, then become thin, watery and very copious; they 
may resemble "rice water" stools of true cholera. There is often asso- 
ciated cramping of the muscles of the calves. The patient is rapidly 
drained of fluid; the face becomes pale and cyanotic, the features pinched 
and the form rapidly emaciates. There is intense thirst, scanty urine. 



INTESTINAL ULCERS 537 

The skin is cold and clammy, though there may be a rise of temperature 
of several degrees. The pulse is rapid and thready. In severe cases 
the patient goes into a state of collapse and may die within forty-eight 
hours. In most cases, however, after a few hours or at most a day or 
two, the symptoms subside, leaving the patient much emaciated and 
prostrated. 

Diagnosis: — When there is an epidemic of Asiatic cholera the differ- 
ential diagnosis is very difficult; the presence of the cholera vibrio in the 
stools is diagnostic. 

Ptomaine poisoning, resulting from eating decomposing proteids, 
gives practically identical symptoms. Arsenic and antimony, when 
taken in toxic doses, produce very similar symptoms. 

Prognosis: — Very few people die of cholera morbus, though in the 
very young or old, or in the debilitated, it may prove fatal. 

Treatment: — An effort should be made to rid the intestinal canal 
of the irritant. Wash out the lower bowel with normal saline solution, 
urging the patient to make an effort to retain it so that a portion may 
be absorbed to make good the rapid draining of fluids from the body. 
In very severe cases it may be worth while to also wash out the stomach 
to check the intractable vomiting. A few small doses of calomel (J grain) 
followed by effervescing magnesium sulphate will aid in sedating the 
intestinal tract as well as in clearing it of poisonous matter. To equal- 
ize the circulation give atropine sulphate 1-250 grain every half hour to 
hour to physiological or remedial effect. Glonoin to produce quick re- 
action. Also support the patient with strychnine arsenate giving 1-67 grain 
every hour or two hours. These remedies may be administered hypo- 
dermically if the stomach is very irritable. For relief of pain and to 
bring about a reaction the chlorodyne granules will prove satisfactory. 
Apply hot compresses or hot flannels to the abdomen and keep the ex- 
tremities warm. Withhold all food during the acute stage of the dis- 
ease, commencing again tentatively with a little hot clam broth or beef 
tea. For the thirst give cracked ice to suck but enjoin the drinking of 
fluids, though iced champagne may be sipped, or a little iced brandy given 
if there is much depression. 

INTESTINAL ULCERS 

Ulcers of the duodenum closely resemble those of the stomach. 
They are generally found above the opening of the bile duct. When the 
healing has resulted in cicatricial stenosis the bowel above the obstruc- 
tion becomes dilated, and the biliary and pancreatic ducts may be 



538 APPENDICITIS 

occluded. Perforation may occasion peritonitis or be walled off and a 
fistulous opening formed into the neighboring viscera. Burns of the 
skin are far more prone to be followed by duodenal than by gastric ulcers, 
and are attributed to embolism and acid digestion of the tissues deprived 
of their blood supply. Chronic nephritis and biliary calculi furnish 
cases. Duodenal ulcers are more common in males from 20 to 40. 
They occur only 1-30 as frequently as gastric ulcers. 

The onset may be marked by intestinal hemorrhages, recurring ir- 
regularly, sometimes with hematemesis, pain coming on two to four hours 
after meals, in the right hypochondrium; violent gastric crises at times 
not related to meals, vomiting likewise not related to eating and giving 
no relief, occasional jaundice if the bile ducts are occluded, with no dor- 
sal pain and no improvement on dieting. Melena in the male sex is 
mostly to be attributed to duodenal ulcer. This and the violent crises 
with pain in the location mentioned are the most diagnostic points. 
Hemorrhoids, cancer, tuberculosis, dysentery and hemophilia are to be 
distinguished. The ulcer may be latent until perforation occurs. The 
induration about the ulcer may afford a tumor simulating cancer. The 
danger to life is greater than from gastric ulcer since cicatrization is 
rarer. The treatment is the same as for gastric ulcer. 

Ulcers form along the colon from the pressure of retained fecal masses. 
Constipation occurs, sometimes occasioning diarrhea, with colicky pains 
and tenesmus. There may be discharges of flaky or thready mucus, pus, 
blood, and sometimes hard black masses are dislodged with relief from 
aching or soreness that may have persisted for a long time. It is we 
believe exceptional for these masses to be detected by physical examination. 
Treatment consists in thoroughly evacuating the bowels and keeping 
them empty until they contract, which may be aided by berberine one to 
five grains daily for months. Stenosis may follow the healing of such 
ulcers. Enemas of coal oil penetrate and disintegrate these masses 
when any amount of water fails to seriously affect them. 

APPENDICITIS 

The vermiform appendix may present catarrhal, suppurative or inter- 
stitial inflammation. The disease may extend to the cecal and peri- 
cecal tissues. 

Pervious during early life, the cavity of the appendix is usually 
obliterated after middle life. It may occupy almost any position in 
the abdomen, the pelvis, or be adherent to any of the abdominal viscera 
or encircle and occlude the bowel. Catarrhal inflammation rapidly 



APPENDICITIS 539 

extends to all the coats of the appendix, the swelling impeding the veins, 
then the arteries, and abscess ensues. In the female a branch supplied 
from the ovarian artery gives a 1 tetter circulation; hence gangrene is 
more frequent in the male. When infiltration occurs, rendering the 
organ firm and rigid, the epithelium may be cast off, the serosa hyper- 
emic and adherent, the tube becomes obliterated and the granulations 
adhere, rendering subsequent attacks impossible. But if only the orifice 
is closed the secretions may distend the appendix perilously. Or the 
mucosa may ulcerate. The result therefore depends largely on the pres- 
ence and degree of stenosis. Perforation may occur. 

Ulceration may be acute or chronic, sometimes accompanying or 
following the catarrhal form, more frequently with concretion or foreign 
bodies. The ulcer may extend or heal, with stricture. 

The interstitial form may also follow the catarrhal or the ulcerative, 
specific bacteria being usually concerned in the process. Gangrene is 
the most common and dangerous lesion, limited to a portion of the tube. 
Perforation and virulent peritonitis is the only termination of this form. 

The peritonitis may be circumscribed or diffuse. In the former 
case there appears a fibrinous exudate which becomes adherent to the 
opposing serous surfaces, walling off the inflammatory products. A 
serous flow follows, forming an appendicular abscess. The location 
and dimensions vary, and it may contain large quantities of pus, thin, 
gray, fetid. The collection may be subperitoneal, and burrow to Pou- 
part's ligament and empty, leaving a fistula for a variable period. The 
pus may empty into the rectum, bladder or vagina, the cecum, colon, 
pleura or the tissues around the kidney, the abdominal wall, hip-joint, 
gluteal region, scrotum, etc. Pylephlebitis has resulted, and erosion of 
an iliac artery with fatal hemorrhage. Thrombi forming in the mesen- 
teric veins have contributed infective emboli to the liver, and iliac throm- 
bosis has occasioned edema of the leg. Acute diffuse peritonitis follows 
perforation when not circumscribed, or when the adhesions give way. 

Etiology: — There may be predisposing causes in structural defects 
stricture or old peritoneal adhesions, fecal concretions in about 50 per 
cent, foreign bodies in 7 per cent, ulcers, straining and traumatisms, 
age — most common between fifteen and thirty — sex — four males to one 
female — gastrointestinal disturbances, possibly heredity, influenza and 
other infect'ons, poor blood-supply and retrogression, with torsion. Flat- 
ulence may and probably frequently does occasion appendicitis, the 
appendix being distended by gas-bearing microorganisms into the cavity. 
Of microorganisms the colon bacillus is most common and staphylo- 
cocci next, while typhoid, tubercle and many others have been found. 



54 o APPENDICITIS 

Constipation favors its occurrence by allowing the numberless organ- 
isms in the bowel time to proliferate and develop malignancy. 

Symptoms: — Many mild cases probably occur and are not recog- 
nized, the affection being attributed to indigestion. The onset may 
be gradual, or sudden if it can be assigned to any special causal occur- 
rence. There may be as prodromes anorexia, nausea, diarrhea or con- 
stipation, with flatulence. The patient may be conscious of abdominal 
discomfort and yet be at his work, until rupture occurs or septic poison- 
ing become apparent. Suppuration may be indicated by a rigor or 
chill. The invasion is heralded by abdominal pain, fever, tenderness 
over McBurney's point, gastric disturbance and circumscribed resistance 
to palpation. McBurney's point is at the middle of a line drawn from 
the umbilicus to the anterior superior spine of the ilium. The pain 
varies widely, and if there are tissues whose circulation is arrested it 
becomes unbearable. It is usually constant with acuter exacerbations. 
Severe pain may indicate peritonitis threatening perforation. It may 
be localized anywhere in the abdomen, but within two days settles on 
the appendiceal region. The fever rises to ioo to 105 ° F., but gravest 
cases may show a subnormal temperature. Some fever is, however, 
the rule. 

The pulse rises above the fever proportionately, with exceptions. 
The tenderness, while usually at McBurney's point, may be at any 
place where the appendix is located — and this may be anywhere in 
the abdomen. The right abdominal rectus is rigid. About the second 
day a circumscribed induration may be found, with swelling that oblit- 
erates the sulci above and in front of the anterior superior iliac spine. 
Not always can the enlarged appendix be recognized in the mass. Vom- 
iting occurs early and may continue, or return on dietary errors or with 
peritonitis. Constipation is the rule; diarrhea may come later or from 
sepsis. The patient lies on the back with the right leg drawn up. At 
first the bladder is irritable, later retention may occur. The course is 
usually favorable, sometimes ending in suppuration, perforation and 
peritonitis. If resolution occurs after a few days the symptoms subside, 
and small pus collections may be absorbed. Perforation may follow 
subacute attacks. The acuter forms show severe pain and quickly 
developing symptoms of peritonitis, the swelling obscuring the tumor, 
temperature falling and vomiting and collapse following. The symp- 
toms are those of acute peritonitis from perforation. The heart fails 
and death results from true "heart-failure" due to acute sepsis. If 
time is permitted the abscess is walled off from the general peritoneal 
cavity. The bowels may then be completely obstructed. 



APPENDICITIS 541 

As the patient lies on the back the affected region may be seen to 
project. The induration and tension yield and the tissues are doughy, 
from cutaneous edema. Fluctuation may be obtained in superficial 
collections. Rectal and bimanual examinations often reveal the diffU 
culty when other methods fail. Percussion may afford dullness or tym- 
panites. Suppuration may occur but the abscess becomes encysted, 
and it may later point in any one of a number of ways. When suppura- 
tion occurs the local symptoms are somewhat relieved but hectic may 
supervene, with diarrhea and colliquative sweats. A cure may follow 
spontaneous discharge in any safe direction. The patient may sink 
into the typhoid state and die. 

Diagnosis: — Typical cases are diagnosed by the sudden severe pain 
in the right iliac fossa, in a previously healthy man under forty, with 
tenderness in the appendix, right rectus abdominis indurated, fever, 
vomiting, usually constipation, sometimes diarrhea. Less marked cases 
may present pains elsewhere, but they soon localize in the appendix, 
or a bimanual and rectal and vaginal examination may reveal the abnor- 
mal location of the affected organ. Induration with intense local pain 
and tenderness indicate approaching perforation. Gangrenous cases 
are deceptive, and the acute symptoms may be wanting or may subside, 
and the patient be allowed to go about until rupture unexpectedly occurs. 

Typhlitis and fecal impaction in the cecum are said to be rare, but 
the writer has in his comparatively limited experience met so many cases 
that he can not subscribe to this. Constipation is present, with drag- 
ging pain, fever coming late, and a doughy, sausage-shaped tumor in the 
region of the cecum and ascending colon, dull on percussion, but with- 
out the localized tenderness and resistance, and disappearing on free 
purgation. In renal colic we have hematuria and pain radiating into 
the groin and the testicle, but no fever nor local tenderness. 

Indigestion may accompany appendicitis, but is relieved by treat- 
ment if alone, and is without the local symptoms and fever. A distended 
gall-bladder occupies a different position and usually there is jaundice 
attending. Perinephric abscess has a different history, of renal disease. 
Ovarian or tubal peritonitis begins lower and has a history of pelvic 
disease. In extrauterine pregnancy the menses have been absent and 
the rupture is followed by collapse from hemorrhage. Acute tuberculous 
peritonitis is less rapid in development, there are no localized appen- 
diceal symptoms, the tumor is movable, and the disease coexists else- 
where. Intestinal obstructions show different localization, with bloody 
stools in intussusception, stercoraceous vomit in strangulation, etc. In- 
testinal sand in the stools mav indicate lithiasis. In acute hemorrhagic 



542 APPENDICITIS 

• 
pancreatitis the deep epigastric pain followed by resistance, and pan- 
creatic symptoms, suffice. A similar decubitus is noted in disease of 
the hip-joint. The diagnosis from typhoid fever seems to require more 
than ordinary care, but surely can not be difficult. Dislocated kidneys 
may closely simulate appendicitis, but the sudden subsidence of local 
swelling and induration, with absence of the kidney "from its proper loca- 
tion, indicate the diagnosis. These attacks from displaced kidney are 
known as Dietl's crises. 

Chronic Appendicitis: — Relapses occur in at least half the cases of 
acute or primary forms. There may be no indications of trouble remain- 
ing, or there may be some sense x>i uneasiness, with tenderness on deep 
pressure, and digestive disorder. The local symptoms are more decided 
at second attacks, but each subsequent one is less decided, as the remis- 
sion is less perfect, considerable pain with some fever occurring at times. 
Exertion and overfeeding are apt to induce attack.s Fecal retention 
is apt to complicate. 

Edebohls thus describes his method of palpation for chronic appen- 
dicitis: "The patient lies upon his back with the examiner at his side; 
the latter places his right hand upon the patient's abdomen over the 
right rectus muscle, opposite the anterior superior spine of the ilium, 
and presses the left hand upon the right, so that no force is used by the 
right hand, and the tactile sense of its fingers is left undisturbed. The 
hands are drawn slowly outward, allowing the contents of the abdomen 
to slip from underneath them. The coils of intestine can be felt as they 
escape from under the hand as it presses against the posterior abdominal 
wall." The appendix may be detected as a tumor the shape of the 
finger, superficial or deeply situated. Pain and tenderness are worse 
if pus is present. 

Each attack inflicts an injury on the patient's health, nervous symp- 
toms developing with emaciation and progressive debility. The patient 
becomes irritable, apprehensive, neurasthenic and hypochondriac. 

Cecal cancer presents more continuous fever and loss of strength and 
weight, and the course is concluded within two to three years. Hypo- 
chondria and hysteria simply require careful physical examinations. 
Oxaluria may cause ureteral irritation that may simulate appendiceal 
localization. 

Prognosis: — In grave cases the local disease shows a tendency to 
spread, with high temperature and rapid pulse, and the local malady is 
intensely toxic. Suppuration occurs and the inflammation extends rapidly. 
Two-thirds of these die within eight days. In the milder form known 
as catarrhal recovery is the rule. The attack is milder and improvement 



APPENDICITIS 543 

is evident by the fourth day. Fitz gives the general mortality of non- 
operative treatment as about 14 per cent. The prognosis in chronic 
cases is, of course, uncertain; but it improves after several attacks have 
been passed safely. 

TreBtmetlt: — Opinions differ widely as to the propriety of invoking 
surgical intervention, the surgeon insisting that all cases are surgical 
and the physician's duty is to call for the operator as soon as the disease 
is suspected. On the other hand many physicians have treated every 
case met during years of general practice, without surgery and without 
a death. The limits are yet to be determined. We can only give gen- 
eral indications for the choice. 

Acute and highly toxic forms with pus-formation and rapid develop- 
ment, those resisting other treatment, relapses increasing in frequency 
and severity, should be subjected to operation. Those for whom surgery 
is not employed should be confined to rest as absolute as can be main- 
tained. The diet should be of articles digested only and completely 
in the stomach — raw beef and oysters, predigested milk, meat powders 
and bovinine or sanguiferrin, raw egg-white, freshly pressed fruit juices, 
and coffee. The quantity should not exceed four ounces every four 
hours. Hot colonic flushes should be used several times a day, aided 
by calomel, gr. 1-6, every hour for six doses and followed by small doses 
of saline laxative every two hours, enough to keep the feces fluid but 
not to excite painful peristalsis. Meanwhile the patient is to be brought 
quickly under the full influence of hyoscyamine, gr. 1-250, every hour 
till the face flushes, and this effect to be maintained by a similar dose 
whenever the flush begins to fade. Give calx sulphurata, a grain every 
hour until saturation, to inhibit microbic activity and prevent or limit 
suppuration. The use of enemas demands skill and judgment on the 
part of the nurse — it is not necessary to risk rupturing the bowel by 
undue violence. 

Cold applications over the affected region are usually advised, but 
many find more relief from very hot ones. Mere counterirritation is 
probably useless. 

During conva 1 escence care must be taken to prevent harm by indis- 
creet exertion or improper food. The bowels must be kept free from 
fecal collections and from fermentation or microbic virulence. The 
intestinal antiseptics should be employed persistently as long as there 
remains a region of low resistance that could be infected. Possibly 
the sulphophenolate of copper may prove of exceptional value here, or 
copper arsenite in doses of gr. 1-100 four times a day. These are 
worthy of more extended trial. 



544 INTESTINAL OBSTRUCTION 

INTESTINAL OBSTRUCTION 

The forms of intestinal obstruction may be divided into the acute 
and the chronic. In the first group are comprised strangulation, 
intussusception and volvulus. Strangulation may be caused by bands 
remaining from a local peritonitis, most common about the ileocecal 
valve. Obstruction by adhesions is seen after abdominal sections, 
from Meckel's diverticulum, the remains of the obliterated omphalo- 
mesenteric vessels, or the appendix. Internal strangulation or hernia may 
follow the inclusion of a knuckle of bowel in Winslow's foramen, or va- 
rious slits and openings in the peritoneal folds. Diaphragmatic hernias 
occur congenitally and from traumatism. Strangulation is most fre- 
quent in young males. 

Intussusception is the telescoping of part of the bowel in another 
part. This is most common at the ileocecal valve, the small bowel enter- 
ing the cecum. Three layers of bowel thus come together. If the pro- 
trusion invades the rectum it may be felt on examination with the finger. 
There follows inflammation, with swelling, and the mass may be strang- 
ulated at the point of entrance and necrosis result. The slough may 
pass by the anus or perforation may occur. This malady is most fre- 
quent in children under 10, and in males. It may follow circular enter- 
orrhaphy or lateral plate anastomosis. 

Volvulus is most frequent at the sigmoid flexure. There may be a 
long loose mesentery, or a local infiltration of a portion of the bowel that 
stops its peristalsis while that of the next segment continues. Men over 
40 years are most subject. 

The chronic obstructions are due to fecal impaction, tumors, cica- 
tricial or congenital stricture, and peristaltic paresis. Impactions are 
most common in the cecum and sigmoid flexure. They may occur in 
childhood but are more frequent in adult women. Hysteria, hypochon- 
dria or dementia may attend, and the degree to which these and other 
psychic maladies may be ascribed to the obstipation is a nice question. 
The colon may be dilated congenitally or later. The fecal masses may 
be channeled or encysted in pockets of the gut, allowing tolerably reg- 
ular passages. The condition of the mucosa when these masses have 
lain long in contact with it cannot but be unhealthy, and the poisoned 
bowel easily falls into the destructive forms of inflammation. Ulcer- 
ation and perforation are common. If the opening is suddenly closed 
symptoms of acute obstruction ensue. 

Enteroliths are hardened concretions, gallstones, lime and magnesia 
phosphates, foreign bodies, food derivatives, etc. The writer has known 



INTESTINAL OBSTRUCTION 545 

fatal obstruction to be caused by masses of charcoal and magnesia. 
The huge doses of iron sulphate given in Blaud's pills have been known 
to leave deposits of ferrous sulphide which occasioned local disease. 
Foreign bodies may lodge anywhere in the small bowel but more fre- 
quently stop at the ileocecal valve. Bismuth and salol may be given in 
quantities sufficient to form obstructions. 

Tumors may develop as neoplasms in the walls of the intestine or 
impinge on its lumen from without. Carcinoma is frequent, circum- 
scribed and annular, or as a diffuse infiltration beginning in the mucous 
membrane or its glands. The sigmoid flexure is the most frequent site, 
or the rectum. The connected lymphatic glands are secondarily affected. 
The disease may be secondary to ulcer or long-continued catarrhal dis- 
ease. Sarcoma is most common in the small bowel, beginning beneath 
the mucosa. It may occur in children. The glands are also affected. 
Benign tumors, of the bowel or the omentum, and pelvic adhesions, 
may cause obstruction. 

The healing of intestinal ulcers present in chronic diarrhea or dysen- 
tery may cause cicatricial stricture, which permits the passage of only 
a definite and decreasing quantity of material. Rectal strictures are 
often syphilitic. Congenital strictures are rare — usually anal atresia. 

Peristaltic palsy may be due to inflammation, enteritis or peritonitis, 
to fecal or flatulent distention, or it may follow abdominal operations. 
The bowel continues to dilate, the walls becoming hypertrophied above 
the obstruction and contracted below it. The tissues in contact with 
the obstruction are inflamed and this may extend to the peritoneum. 
Consequences may be the formation of a false membrane, gangrene, 
ulceration, perforation, and local or general peritonitis, with all its dire 
symptoms. 

Symptoms: — In acute cases there are suddenly developing abdominal 
pains, perhaps following exertion or strain. The pain may become 
unbearable, with exacerbations. Vomiting soon follows and the consti- 
pation is absolute. Hiccough and eructations occur if the obstruction 
is high up in the small bowel. The early symptoms are rather of strang- 
ulation than of obstruction of the bowel. Tympanites appears later, 
most marked in colonic obstructions. The pain is of the agonizing 
nature peculiar to tissue strangulation. The vomiting increases in 
severity and constancy, alternated with retching. The contents of the 
stomach are voided, then mucus, bile, and finally fecal material. Rapid 
and profound collapse develops quickly, with cold nose and extremities, 
small weak pulse, pinched face, cold perspiration and profound depres- 
sion of the vital forces. 



546 INTESTINAL OBSTRUCTION 

The temperature is subnormal, respiration shallow and fast, the 
expression that of anxiety, the urine scanty, and thirst excessive. The 
abdomen is swollen, tympanitic and very tender. Excited motion of 
the bowel may be seen above the obstruction, gurgling and splashing 
heard on auscultation. 

In chronic obstruction the symptoms of the cause will be presented. 
The obstruction is not complete, but increases gradually, as denoted by 
increasing constipation. Diarrhea may be excited, with colic and 
increasing tympanites, vomiting and prostration. Complete obstruction 
may occur suddenly or gradually supervene. If the bowel is compressed 
from without, the stools are flat, ribbon-like, while if the stricture is uni- 
form they are like pipe-stems. If the obstruction is in the small bowel, 
whose contents are fluid, there may be little or no constipation. Some- 
times a tight stricture here is obstructed by a morsel of food, and vomit- 
ing will continue until the offending substance has been ejected. The 
rectum may be distended by fecal masses in young infants or in the aged. 

In cancerous cases we have the cachexia and progressive loss of weight 
and strength. Inspection shows distention above the obstructed point 
with excited motion. Palpation may detect a growth. 

Diagnosis: — Sudden, severe increasing abdominal pain, persistent 
vomiting becoming stercoracious, complete constipation with tympanites, 
with deep and early depression, indicate acute obstruction. The loca- 
tion may be inferred from the character of the vomiting, which is only 
fecal when the large bowel is obstructed. The distension is less when 
the small bowel is obstructed, and there is less tenesmus. Mucus 
and blood indicate irritation of the large bowel. Palpation may 
locate a tumor or stricture. If the upper small bowel is alone obstructed, 
indol and phenol are absorbed, and indican appears in the urine, which 
is not apt to be the case when the large bowel is obstructed. Examin- 
ation by the rectum or vagina may give valuable information, as also 
will distention of the bowel by water or gas thrown into the rectum. 

In strangulation we have a history of peritonitis, abdominal opera- 
tion, or recurrent attacks of abdominal pain, with early fecal vomiting, 
mostly in young men. Intussusception occurs suddenly in a child with 
colicky pain, tenesmus, mucous and bloody stools, and a sausage-like 
tumor, while the constipation is not absolute, nor the tympanites marked. 
Volvulus occurs in the aged following intestinal atony, constipation, 
flatulence or local inflammation. Tympanites is marked, with abdominal 
rigidity, dyspnea and local tenderness. Fecal obstruction follows obsti- 
nate constipation and the onset is gradual. There is not much tym- 
panites, and vomiting only occurs late if at all. Palpation may detect 



INTESTINAL OBSTRUCTION 547 

fecal masses which may even pit on pressure. Sometimes there has been 
a gradual enlargement of a part of the abdomen. The tenderness is 
slight. Obstruction from gall-stones or other intestinal contents such 
as foreign bodies may be surmised from the history, but are otherwise 
difficult of positive diagnosis. In the chronic forms we have the history 
of chronic diarrhea with ulceration, tuberculosis, carcinoma, sarcoma or 
other disease. Intestinal paresis follows enteritis, peritonitis or abdom- 
inal operation. Peristalsis cannot be perceived, and tympanites is gen- 
eral. Peritonitis may be distinguished by the history, early and high 
fever, peculiar radiating pain, vomiting not fecal, late collapse and leu- 
cocytosis in septic cases. The abdomen is generally and markedly 
distended, peristalsis invisible, tenderness decided and general, the 
sounds on auscultation not prominent, and effusion follows. In acute 
enteritis we have diarrhea with mucus and bloody stools, fever and in- 
tense pain, the stomach being usually most affected by corrosives. 
Abdominal colics differ widely in the history, previous to and during 
the attack. 

Acute obstructions end within a week; the chronic may run for 
months. The prognosis is bad in all. Complications are peritonitis, 
gangrene, sepsis and enteritis. 

Treatment: — Fecal impactions are best broken up by coal oil 
enemas; from one to four pints may be injected as far up the bowel as 
possible and after one hour may be washed away by copious warm 
enemas. This may be repeated according to the indications. Intus- 
susception and volvulus may be relieved by distending the bowel with 
hot water or with air, care being taken not to cause rupture by overdis- 
tension. Abdominal massage with hot camphor liniment is also a valu- 
able resource. As some forms of obstruction are due in part to spas- 
modic contraction it is always advisable to bring the patient rapidly 
under the influence of hyoscyamine, which is far superior to morphine 
in this instance. When there is a mechanical obstruction, like stricture 
or occlusion by a foreign body, or when cancer or other tumors occasion 
the trouble, surgical intervention alone is indicated. Anders says that 
acute forms require surgery, but clinicians see too many cases in which 
the peril appears imminent, and yet recovery ensues when the patient 
is brought fully under hyoscyamine, and enemas bring to light incred- 
ible quantities of seeds, cherry stones, half masticated peanuts, or other 
food residues, to be stampeded by such statements. Tympanites has 
been relieved by withdrawing the gas by means of a very fine trocar 
and canula. When time permits physostigmine relieves this symptom. 
Constipation and intestinal atony are discussed elsewhere. 



548 CARCINOMA OF THE INTESTINE 

CARCINOMA OF THE INTESTINE 

" 

This is a common cause of chronic intestinal obstruction. The 
stenosis gradually increases until there is a breaking-down of the can- 
cerous masses, when this symptom is relieved. The malady is usually 
secondary. 

The most common form is cylindrical epithelioma, although scirrhous, 
medullary and colloid forms may occur. It may be annular, polypoid 
or an infiltration. The abdominal glands are affected later. It is most 
frequent in the rectum, then in the sigmoid flexure, transverse and 
descending colon, duodenal papilla, ascending colon, and the lower and 
middle ileum. Above the obstruction the bowel is dilated and hyper- 
trophied, fecal matter collecting there. Below the tumor the bowel is 
contracted and atrophied. 

The causes are those of cancer; old age and intestinal ulceration are 
the principal features. 

Symptoms: — The patient complains of shooting pains and increasing 
distress at first following defecation, but becoming more constant. Diar- 
rhea alternates with constipation. The feces contain blood and mucus. 
Cachexia developes, there is a little fever, the patient steadily loses weight 
and strength and an anxious expression becomes fixed. The anal sphinc- 
ter may be paralyzed, and incontinence result. Sometimes there is ab- 
solutely no symptom excepting constipation, that is controlled by constant 
care, until the obstruction becomes practically complete. There may 
be even not enough cachexia and autotoxemia manifest to attract attention, 
although quarts of fecal matter are retained. Colicky attacks however, 
are apt to occur, with abdominal uneasiness and flatulence. If the can- 
cer is in the large bowel, the shape of fecal masses may be altered. 

A tumor may be noted on inspection, with peristalsis above it and quiet 
below, or the mass may be outlined by palpation, and dullness elicited 
by percussion. Boas' sign is the sudden appearance of small coils of 
bowel, vanishing quickly and reappearing. 

The diagnosis may be made by the age, cachexia, pains, bloody stools, 
the firm nodular tumor, persistent and not movable, with pigmented skin, 
small angiomas and capillary hemorrhages. Most of these symptoms 
occur singly with other maladies. The location may be fixed by distend- 
ing the bowel. 

The course varies with the variety, soft cancer destroying life in a few. 
months, the hardest ending within three years. Death may be due to per- 
foration and peritonitis, rupture from overdistention, extension, ulceration 
and sepsis. The prognosis could scarcely be worse. 



CONSTIPATION 549 

The treatment is surgical, and by this means life may be prolonged. 
A question to be decided is whether condurangin, which has notably suc- 
ceeded with cancer of the stomach, would succeed if applied locally to 
rectal cases where the tumor is within reach. The writer has employed 
this agent in one case of rectal cancer, rather imperfectly, as the treatment 
was carried out at the patient's home by an inexperienced nurse. Never- 
theless the patient was firm in his belief that the remedy greatly relieved 
him and prolonged his life. Much of the suffering is removed by any 
measure which will insure the patients against fecal collection. In this 
case a milligram of condurangin was dissolved in a dram of warm water 
and a pledget of cotton saturated with this solution, placed in contact 
with the tumor after cleansing by copious enemas. 

When colotomy has been performed and the fecal stream diverted 
from the cancerous rectum, not only has the relief been great, but the 
progress of the cancer seems to be markedly delayed. 

CONSTIPATION 

Etiology: — There may be a deficiency either in the fluidity of the 
intestinal contents or of the sensory irritability and peristaltic power, or 
both. Among the general causes may be mentioned the sluggish tem- 
perament disposing the patient to muscular inactivity, the habits of a 
sedentary life and the neglect of that regularity which is absolutely nec- 
essary to the healthy exercise of the function; general debility and that 
due to chronic disease; the use of concentrated foods with little resi- 
due; the use of too little water or that which has a constipating quality, 
and the loss of excessive quantities of water through the kidneys and 
the skin. Among local causes may be mentioned, atony of the abdom- 
inal muscles from obesity or following parturition; atony of the large 
bowel from chronic catarrh and habitual distention; pressure from with- 
out as from a retroverted uterus; intestinal stenosis from internal causes, 
and continuous muscular contraction, such as occurs in lead poisoning. 

Symptoms: — The term constipation is relative, for while one person 
may require two movements a day, another may enjoy comparative 
health with one a week. In general it may be said that constipation is 
a disease when the patient experiences any evident symptoms from it. 
These symptoms may be direct, such as the sense of fullness, weight or 
pressure in the abdomen, flatulence, colic and the irritation expressed 
by diarrhea. The general symptoms are those now comprehended 
under the term "fecal autotoxemia," decomposition going on in the 
retained substances, and the toxic results being absorbed in the blood. 



550 CONSTIPATION 

These are carried to every part of the body, exerting on all a deleterious 
influence. The effect will be manifested at the points of lowest vital 
resistance. Hence we may have the so-called reflex symptoms appear- 
ing anywhere in the body. These may be somatic or psychic. Among 
the more common are a sense of malaise, dullness, irritability, headache, 
flushes, palpitation, cold feet, loss of appetite, vertigo, insomnia, dis- 
turbed sleep and bad dreams, innumerable paresthesiae, neuralgias, 
various skin eruptions, disorder of the liver, kidneys or other organs, 
uterine affections, aggravation of mucous catarrhs and the appearance 
of small foci of suppuration in the skin especially. The digestive func- 
tion is invariably affected. Fever may be present, and in fact a continued 
fever may be excited resembling typhoid fever, and with difficulty dis- 
tinguished from it. The liver is early intoxicated, and as a result we 
have disturbed digestion and portal obstruction with gastroenteritis and 
hemorrhoids. Local disease of the intestinal walls is induced. 

The diagnosis is easy enough, although it is difficult even for exper- 
ienced practicians to realize how completely a grave case of fever or 
even unquestioned mental derangement may depend upon constipa- 
tion. The prognosis is good. Nothing will excuse the neglect of 
hygiene. 

The patient must be taught to eat the proper food in the proper 
manner. Fruit and such articles as contain an irritating indigestible 
residuum should be employed. Among those we mention oatmeal, corn- 
meal and flour from the entire wheat; raw prunes, figs and dates are 
excellent if thoroughly masticated. A sufficiency of bodily exercise is 
imperative, and such exercise as affects the abdominal muscles is essen- 
tial. Perhaps nothing equals the use of a buck-saw. Sufficient water 
should be used, and it is good practice for the patient to drink a pint 
of cold water immediately on rising. Cascara and aloin are the two 
remedies believed to act specially on the musculature of the large bowel. 
The writer has for many years employed a combination of aloin, strych- 
nine, atropine, emetine and oleoresin t>f capsicum, to which recently a 
trace of bilein is added, with the best results. This he believes to be 
the best means of obtaining a cure. 

If the treatment of constipation consisted simply in the administra- 
tion of a cathartic, or of a succession of cathartics, there would be little 
need of writing on the subject. The long list of laxatives, drastics, 
hydragogues, etc., from bran to elaterium, would seem to cover every 
possible case requiring evacuation of the bowels. 

But cathartics do not cure constipation. In fact, they only make 
it worse, by lessening the natural power of the bowel and getting the 



CONSTIPATION 551 

patient into the habit of depending on outside aid to force his rectum 
to perform its functions. It is well known that, when once this depend- 
ence upon drugs is formed, larger and larger doses are required, until 
the victim is finally unable to have a passage without the aid of a 
boxful of patenf pills, or the most powerful of the cathartic group in 
enormous doses. It is this principle that has made the fortunes of 
the patent-pill-venders, whose advertisements are never absent from 
the papers. The injury done by these men, in making chronic 
drug-takers of their patrons, is great. 

The same condemnation must be made of the laxative waters, foods, 
suppositories of gluten or glycerin and enemas small or large. Not one 
of them cures; all must be classed as of that vicious group of palliatives 
that confirm the original disease. 

And this disease is a diminution of the sensibility of the colon and 
rectum, by which these organs retain the feces and become distended 
by them, instead of being excited by their presence to expulsive con- 
traction. The prime cause of this loss of sensibility is neglect. The 
presence of feces is noted, but as it does not suit the individual to go 
just then, the duty is put off until the pressure is imperative. 

Meanwhile the bowel is becoming accustomed to the presence of 
feces and is gradually becoming transformed into a cavity for storing 
the same, instead of an organ for their expulsion. As the muscular 
movements grow weaker, the bowel may be dilated until very large 
quantities may be stored in it. Reynolds relates a case in which 
a woman had her bowels opened but four times a year, taking a break- 
fast cup of pills for that purpose and filling a wooden bucket with masses 
as large as a baby's head at birth. 

Women are the greatest delinquents in this respect. It is exceed- 
ingly rare to find one who performs the duty of going regularly to the 
closet every day at the same hour. In twenty-five years of practice I 
can recollect but one who did this. And yet it seems strange that the 
beauty-specialists have not yet found out that the daily evacuation "and 
the morning cold bath, with open air exercise, are worth all the cos- 
metics, paints, powders, pastes, frictions, massage, etc., which they 
vaunt so loudly, for the female complexion. But I may be wrong — 
they doubtless have discovered it, but these agencies cannot be peddled 
about at $2.00 a bottle. 

No cosmetic can remedy the muddy, pimply, blotchy complexion; 
no tonic restore the look of health to the woman who is constantly 
absorbing into her blood, from her alimentary canal, the liquid portion 
of her feces. 



552 CONSTIPATION 

The indications for treatment are very simple: To open the bowels 
and keep them open daily by as little help as is necessary, until the 
influence of habit has restored the organs to their normal functions. The 
hour most suitable in each case should be selected, and the patient 
enjoined to go to the closet daily at that time. The mqre precisely the 
time is fixed, the greater the likelihood of the direction being obeyed. 
To insure the action we know no remedy as efficient as the laxative 
granule. 

The effect of the ingredients is as follows: Aloes stimulates the peri- 
staltic action, especially affecting the muscular fibers of the rectum. 
The dose of aloes should never exceed one grain (or of aloin one half 
grain). Large doses do harm and' do not give the tonic action sought, 
but exhaust the irritability by over-stimulation. 

Strychnine promptly increases the peristaltic action, and also the 
sensitiveness of the mucuos membrane, thus rendering it less tolerant 
of its contents and affording more power to throw it off. 

Atropine lessens the tendency of these drugs to cause griping, while 
it favors their laxative action by paralyzing the terminal ends of the 
splanchnic inhibitory nerves. As it lessens secretion, the addition of 
a minute amount of emetine is advisable, especially when the stools 
are already abnormally dry or costive. As this condition most frequently 
results from the too free use of very cold water, patients should be cau- 
tioned against the use of iced water, ices, and ice cream. 

The last ingredient is capsicum, added to stimulate secretion and 
increase the sensibility of the mucous membranes. This is. one of the 
most important ingredients, as I have never been able to get as good 
results from the others when the capscium has been omitted. 

Sufficient of these laxative granules are to be given to insure one pas- 
sage daily. This dose must be divided into three portions, one to be 
taken before each meal. In a few days it will be found. that the dose can 
be diminished somewhat; and, as the bowels become stronger and the 
habit of regularity is established, the number of granules is gradually 
lessened until but one is necessary. Then one is to be taken twice a day, 
then once; but this last granule should not be dropped for a long time. 
The moral effect of it is similar to that of a " buckeye " carried in the 
pocket. Indeed, it would be well to give the patient a box of dummy 
pills, placebos, to take after the need of real laxatives has passed away, 
so strongly is the connection between pill and passage fixed in his mind. 

What these granules will do is to cure chronic constipation, if the 
rules as to taking them and as to regularity be observed. They 
not cure if these rules be neglected. 



DILATATION OF THE COLON 553 

They will not cure obstruction due to stricture, torsion, pressure 
from outside the bowel, or occlusion of the gut by a foreign body. 

They will not remove an impaction of feces. Their function is to 
prevent the reforming of such a collection after it has been removed by 
enemas or by active cathartics. 

They are not so well suited for the obstinate constipation of paretics 
(" softening of the brain") as the cold, saturated, salt-solution enema. 

The formula of this combination is as follows: Aloin, gr. 1-25; 
strychnine sulphate, gr. 1-500; atropine sulphate, 1-2500; oleoresin 
capsicum, gr. 1-500; emetine, gr. 1-500. 

DILATATION OF THE COLON 

The entire colon may be dilated or any part, acutely, more frequently 
chronically. This may be the part above a constriction, or one part 
being dilated that below it is relatively narrowed and feces collect in the 
relaxed portion. Enormous dilatation and huge masses of feces may 
be found, even distorting the shape of the abdomen. The bowel may 
be thickened, hypertrophied, ulcerated or catarrhal. While constipation 
is present there may be small, insufficient passages daily. 

The diagnosis may be made by inspection and palpation, distending 
the bowel with gas or water, and sometimes by percussion. 

The fecal masses are best broken up and evacuated by enemas of 
kerosene, followed by large colonic flushes of warm water, and continued 
administration of salines. When all retained feces have been removed 
the dilated bowel may be contracted by the use of strychnine, physo- 
stigmine or berberine, alone or alternated, each given to full effect and 
this sustained. We usually give each of these for a week in succession. 
Meanwhile the diet should be irritant in quality and small in bulk, the 
dilated bowel being never permitted distention. Internal faradism is 
useful, the negative pole applied to the fluid in the colon through an 
electrode insulated to near the tip. Cascara acts specifically on the 
large bowel, and doses exactly enough and no more to keep the bowel 
regular may be given after the cure to prevent return. Or, the laxative 
granule mentioned in the chapter on constipation may be employed; 
with a granule of physostigmine and gr. 1-6 of berberine, to three or 
live of the laxatives, at each meal. Pains must be taken to see that no 
reaccumulation is permitted and that the cathartic habit is not formed 
on the other hand. 

Mechanical obstacles like strictures are only to be relieved by surgical 
measures. 



554 MUCOUS COLITIS 

MUCOUS COLITIS 

This disease is much more common than most physicians imagine. 
While its severe and typical forms, which are mainly described in the 
text-books, may not be so very common, there certainly are very many 
cases of a milder type which entirely escape diagnosis, and in which 
frequent attacks of colicky pain and diarrhea are ascribed to a variety 
of other causes, such as simple intestinal colic, inflammatory colitis, 
acute indigestion, gastralgia, ovarian colic, gallstone colic, and appendi- 
citis. And yet the diagnosis is not as a rule very difficult — though the 
differentiation from true inflammatory colitis is not always as simple 
as we might desire. 

Etiology: — There is great difference of opinion among author- 
ities as to the nature of membranous catarrh of the intestine. There 
are two schools: One regards it as a secretory neurosis, with no 
inflammatory basis; the other, while admitting the nervous factor, 
ascribes its symptomatology partially at least to inflammatory changes 
in the mucous membrane of the intestine. The former, as led by Von 
Noorden, is now the dominant school. And yet it is universally admit- 
ted that in a variety of inflammatory diseases of the intestine there is a 
nosologic picture which clinically is indistinguishable from non-inflam- 
matory catarrh, the colica mucosa of Von Noorden. Recent French 
writers have especially emphasized this relationship and have classified 
and described a series of symptom-pictures which in many respects par- 
allel the true secretory neurosis. They have shown that there is a group 
of true intermediary forms which serve to bind together the more pro- 
nounced and unmistakable colon inflammations and true colica mucosa. 
"Is there," say Mathieu and Roux, "identity of nature between muco- 
membranous colitis, properly so called, and colitis with mucous hyper- 
secretion ? The existence of intermediary forms may be invoked in favor 
of the unity; but in reality we can make on this subject but gratuitous 
hypotheses." The subject is one capable of prolonged discussion, which 
we have not room for here. But after some consideration of the ques- 
tion, it seems to me that pure neurotic forms of colitis rest at one end of 
a scale, pure inflammatory forms at the other, and that there may be a 
number of intermediate forms, many of which undoubtedly present slight 
inflammatory complications, while other forms are perhaps inflammatory 
in their inception, even though this factor has since ceased to play 
a part. 

Mucomembranous colitis occurs mainly in women and almost inva- 
riably in those of a neurotic type. It is on this nervous instability that 



MUCOUS COLITIS 555 

it mainly depends, in the same way as the neuroses of the stomach. 
Indeed, with this intestinal hypersecretion we have, in many cases, a 
history of gastric hypersecretion or hyperchlorhydria. This has been 
noted almost without exception in the few cases I have observed; the 
hyperchlorhydria was very marked for a year or two preceding the incep- 
tion of the intestinal trouble in one case to which I have called especial 
attention. The neurotic factor is so important that it deserves special 
investigation in every suspected case of this kind. As bearing upon this 
point the gastric hysteric stigmata referred to by Mathieu and Roux have 
frequently been observed by me, and will certainly be found present in 
a large percentage of cases. These are (1) marked hyperesthesia or 
sensitiveness to pressure in the gastric region; pressure in this region 
causing a peculiar sickening pain, varying greatly in intensity, this being 
due to hyperesthesia of the solar plexus and the chain of sympathetics 
lying along the abdominal aorta; (2) the presence of areas of increased 
or diminished sensibility in the skin of the abdomen. These hysteric 
stigmata I have observed in some of these cases of colica mucosa, and 
I believe they throw some light upon its causation. 

Neurasthenia, the exhaustion neurosis, is also present in a very large 
percentage of cases, though it is not always easy to demonstrate its exis- 
tence prior to the development of the intestinal trouble. Thus, in 304 
cases investigated by de Langenhagen, in only sixteen had the neuras- 
thenia preceded the intestinal disorder. Nevertheless the neurotic rela- 
tionship cannot be evaded; there is undoubtedly a neurotic soil, whether 
hysteric or neuralgic, in most of the cases of this disease. As Caley says 
in a recent number of the British Medical Journal: "It seems as if we 
can hardly evade the vicious circle; neurasthenia predisposes to colitis 
and colitis induces or aggravates the neurasthenia. " 

Attention has recently been called to the relation of arthritism to mem- 
branous colitis, and de Langahagen makes the flat-footed statement that 
"the arthritic diathesis is found at the origin of every mucomembranous 
enteritis." This has not struck me in the few cases I have seen, but is 
worthy of investigation, inasmuch as Caley says, the relationship seems 
to be rather "with the chronic and fibrous forms of articular and muscular 
rheumatism (fibrositis) than with acute rheumatism." Since there are 
excellent reasons for belief that many of the so-called rheumatic cases of 
this description are consequent upon and due to intestinal autointoxi- 
cation, is it not possible that this arthritic condition is due to, rather than 
the cause of, the bowel disturbance, a condition notoriously likely to favor 
the production of intestinal poisons? The relation of neurasthenic 
troubles to antointoxication is undoubted. 



556 MUCOUS COLITIS 

One point that has particularly interested me has been the frequency 
with which 'the patients suffering from colica mucosa presented visceral 
prolapse, splanchnoptosia, in varying degree. Whether relaxation is due 
to a common cause, the neurotic weakness and lack of tone, or whether 
there is a true anatomic relationship, the result being interference with 
nutrition of the bowel through choking of the vascular supply, is an in- 
teresting question. 

One symptom which is constant in these cases also undoubtedly acts 
as an exciting cause: the constipation. This is always present and prob- 
ably always precedes the paroxysmal attacks. 

We may assume that the pathogenesis is about as follows: (i) A con- 
dition of general reflex irritability, due to the neurotic condition; (2) a 
localized irritability of the intestine, with or without superficial irritation 
or true inflammation — possibly and even probably a sub-inflammatory 
state in many cases; (3) localized or general spasm of. the colon, this being 
the cause of the constipation, which, whatever its inception, sooner or later 
becomes spasmodic in type. These give us the indications for treatment. 

Symptoms: — There are three important symptoms, and these for 
all practical purposes are always present. These are: constipation; 
the presence of mucus in the stools; and paroxysmal pain. 

The constipation is not always recognized, simply because in many of 
these cases, perhaps in most of them, there are frequent attacks of diarrhea, 
usually though not always accompanied by the characteristic pain. But 
in spite of the diarrhea there is invariably more or less fecal stasis and 
an accumulation of fecal matter, which is rarely if ever entirely removed. 
The stools are variable. In many cases they are the characteristic ribbon 
or pencil stools of spasmodic constipation; in others the patient passes 
rounded hardened scybalae, the so called "sheep-dung stool"; another 
form which I have observed, usually alternating with one of the others, 
is a formless stool consisting of an admixture of mucus with fecal matter, 
having the appearance of brown sugar; upon stirring it entirely disinte- 
grates, the mucus floating on the water. At times the patient's stools will 
be apparently normal in appearance but there is a tendency for the above 
described forms to reappear at every fresh access of the affection. 

Mucus is invariably present in every case though not in every stool. 
It is clear and there is no admixture with blood, as in the case of the true 
inflammations, proctitis or sigmoiditis. If blood is present the presump- 
tion is that we have a true colitis, not .a neurotic hypersecretion. The 
quantity of the mucus varies greatly; usually with severe paroxysms of 
pain if the quantity is large. According to Von Noorden the pain is due 
to the fact that the mucus adheres very closely to the bowel wall, and 



MUCOUS COLITIS 557 

being detached with great difficulty severe spasmodic action is the result 
at every stool. The form in which it is voided varies greatly. Usually 
it appears as tough strings of mucus, more rarely in partial casts of the 
bowel. In one case the patient called my attention to the strings of mucus 
which were five or six inches in length, because she thought she was pas- 
sing a tape worm or some other intestinal parasite. The strings are often 
very tenacious. At other times, as in the loose flocculent stool which I 
have described, the mucus will be intimately mixed with the fecal matter. 
Such a stool, when stirred a little, will often be found to consist very largely 
of pure mucus. 

The attacks of pain usually accompany movement of the bowel or 
attacks of diarrhea. It is sudden in its onset and paroxysmal in its char- 
acter. It is usually very severe, accompanied by a sickening sense of 
faintness; at times the patient may even loose consciousness, though 
this is not common. After the attack of diarrhea subsides the pain usu- 
ally disappears, though the patient usually experiences a sense of weakness 
or depression following such an attack. At other times there may be a 
succession of diarrheal attacks, covering a period of several hours or even 
days, and the pain is more or less continuous during that time. The 
severity of the pain, as Von Noorden declares, seems to be proportionate 
to the quantity and tenacity of the mucus, and this again seems to depend 
upon the degree of constipation. 

Treatment: — The principal indications for treatment are about as follows : 

1. To cure the constipation and prevent its recurrence. 

2. To correct any local irritability of the bowel, which by response 
to stimulus seems to excite spasm and increase constipation and pain. 

3. To restore the normal tone to the nervous system, and while doing 
this to increase the nutrition of the body. 

The method of treatment advocated by Von Noorden addresses itself 
almost entirely to the cure of the constipation. While recognizing 
the importance of treating the nervous system he says: "If it is found 
impossible to treat the patient in all directions the chief attention should 
be given to the intestine, for regulation of the bowels invariably leads to 
a rapid cure of any case of colica mucosa." 

The treatment of this disease advised by all authors is mainly dietetic, 
but in outlining a regime there is a wide divergence of opinion. The 
methods of Von Noorden are those most popular in Germany and in this 
country — and deservedly so. Since he believes that the constipation is 
fundamental and ascribes practically no importance to the local condition 
of the bowel he advocates giving a diet which aims only at one thing — it 
must be generally laxative. He therefore advocates food that is very 



558 MUCOUS COLITIS 

coarse, and that contains a large proportion of indigestible residue. He 
orders Graham bread, 250 Gm. or more a day, and in addition as great a 
variety as possible of leguminous foods, including their husks, vegetables 
containing much cellulose, fruit with small seeds and thick skins, besides 
large quantities of fat. The stools after such a diet are large, and surpri- 
singly soft and non-irritating. 

The older method of dieting, and that still mainly advocated by French 
authors, prescribes a diet which is primarily intended to be non-irritating. 
As one recent writer puts it: "The food should be (1) rich in nitrogen, 
carbohydrates and fats to assure a well balanced ration; (2) comprise only 
foods which bring into exercise as slightly as possible the motor function 
of the intestine; (3) be composed only of fresh materials. " These authors 
prescribe mainly farinaceous foods in the form of purees, gruels, etc; all 
the coarser elements being carefully excluded. 

There can be no doubt that the methods advocated by Von Noorden 
are vastly superior and are applicable in the vast majority of cases. I 
have found some difficulty with the very coarse diet, however, in some 
cases, due probably to faulty technic, sinCe these were home-treated cases 
and a rigid diet was not easily secured. In such cases I have however, 
had good success by adding a large amount of fat to the regular diet, usu- 
ally in the form of cream, which was ordered at and between the regular 
meals, in much the same way as the milk diet is prescribed in the modern 
treatment of consumption. The great difficulty I have experienced is to 
persuade these patients to take enough food. Most of them are dainty 
feeders, of small appetite and accustomed to living largely on toast, tea 
and such things. Increase the amount of food, for if you can "fat up" 
almost any neurasthenic she will show improvement. 

The ordinary laxatives are likely to do more harm than good in colica 
mucosa. We are dealing here in most cases with a spasmodic constipation. 
The common laxatives increase this spasm and only cause evacuation at 
the expense of the bowel, with increase of pain and increase of mucous 
irritation. Probably the best method to unload the bowel during an 
acute attack is by warm enemas — not hot nor cold, since warmth is re- 
laxing while either extreme heat or cold is stimulating. This should be 
introduced gradually, without pressure — just allowed to run in. The 
addition of a little salt or soda helps to detach the adherent mucus. The 
oil cure of Kussmaul admirably meets the indication in most cases. From 
four to eight ounces of olive oil are injected into the bowel at bedtime and 
retained if possible through the night. It may be well to precede the oil 
by the water enema as just described, to unload the lower bowel. The 
oil serves to soften the hard feces which may be and usually are retained. 



MUCOUS COLITIS 559 

During acute attacks relief of pain may be secured with hot applications 
to the bowel and unloading the intestine by the means just described. 
In addition most authors advise recourse to morphine or opium. While 
these narcotics may occasionally be required by the intensity of the pain, 
in the majority of cases better and every way more satisfactory results may 
be obtained with atropine. This has the advantage of being not only 
narcotic but it relaxes spasms and diminishes reflex irritability, thereby 
meetkig the second indication perhaps better than any other remedy. 
During acute attacks atropine should be given to physiological action, 
shown by dryness of the throat and mouth; rarely is it necessary to push 
it to the point of reddening the skin and dilating the pupil. I also believe 
that atropine is the internal remedy of most value for continuous use, to 
diminish the irritability of the intestine. But for prolonged use it should 
be given in very small doses, 1-1000 of a grain three or four times a day; 
possibly twice this dose may be necessary or desirable in some cases, but 
usually in these doses it has a decidedly soothing effect, and by checking 
the response to slight irritation it tends to relieve both spasm and consti- 
pation. In this sense atropine is certainly a valuable laxative, perhaps 
the most valuable w r e have in spasmodic constipation, a condition in which 
only the slightest peripheral or central irritation is sufficient to cause tem- 
porary closure of the lumen of the bowel. Morphine and opium, while 
normally checking secretion and peristalsis, have a similar effect and upon 
occasion may be useful as laxatives, and to relax spasm generally, but the 
objection to the use of morphine continuously is too apparent to need 
comment. Another advantage of atropine thus used in these cases is its 
influence on the secretory function of the digestive tract. As we have 
already pointed out there is in these cases hypersecretion, not in the intestine 
only but throughout the digestive tract, the stomach especially; the action 
of atropine in small doses can therefore hardly fail to be beneficent. 

Is the local condition such as to require local medication ? Von Noorden 
and the others of his school say no, and in general we may agree with them. 
But in many cases an effort tow r ard local medication certainly seems ad- 
visable, at least to remove sources of irritation such as the irritant toxins 
developed in fecal matter. Theoretically the sulphocarbolates would 
seem indicated to check putrefactive processes, which are certainly 
present in these cases and besides their local action mast contribute to the 
general state of innutrition. But I have found these salts irritant in these 
cases — poorly tolerated. Copper arsenite, on the contrary, seems to have 
a good effect and is both tonic and sedative to the mucosa. It deserves 
further trial. Arbutin which exerts so marked an influence in restoring 
the normal conditions to catarrhal or relaxed genito-urinary mucous 



5 6o MUCOUS COLITIS 

membrane, has a similar but less marked control over the intestinal mucosa. 
It is possible that in rhus tox we have a similar agent whose influence is 
most particularly exerted over the bowel, and many observers have testi- 
fied to this. This is as yet, however, in the stage of experiment, with in- 
dications favoring the claim. 

In one case of many years standing one of my colleagues has obtained 
considerable benefit from colonic flushing with warm water impregnated 
with volatile oils, repeated daily for a month or more. A valuable sedative 
in all nervous diseases, acting through the central nervous system, is cicu- 
tine hydrobromide. While a powerful sedative it is not a habit forming 
drug and may be taken with perfect safety and with undoubted satis- 
faction. 

While removal of the exciting cause, the constipation, undoubtedly 
serves to eliminate the symptom-complex which we are describing, to 
insure the permanency of the cure and restore the patient to normal health 
it is necessary to treat the underlying condition — the neurosis. This is, 
in the main, a matter of improvement of digestion and assimilation: for, 
as I have said before, if you can make one of these patients fat — and by 
this I mean not flabbily fat, but a genuine increase in the essential tissues 
of the body — you have cured her. The dietetic measures addressed to the 
constipation are therefore at the same time beneficial to the nervous state. 
Plenty of food, food which can be digested and assimilated, this is funda- 
mental. But since the digestion of these patients is often feeble this may 
require medicinal aid. In the case to which I have previously referred 
the best results were obtained with a cream diet, giving at the same time 
pancreatin and the bile acids. In this case gastric digestion was fairly 
good, indeed there was an excess of HC1, but intestinal digestion seemed 
to be poor and the depurating action of the liver feeble. Any medication 
of this kind must meet the special condition. However, I have a feeling 
that the condition of the liver is too often neglected in these cases. Some- 
times, as in the lienteric diarrhea preceding rickets, there is evident in- 
digestion of starches, and the addition of diastase in full dose prove an 
efiicient adjuvant. 

These patients are often anemic and in such cases arsenic seems to act 
better than other medicaments. I have found no remedy more generally 
useful in neurasthenics, whatever the line of symptomatology, than strych- 
nine arsenate. Similar salts of iron and quinine may be added, and there 
are many testimonies to the value of nuclem in these cases. The tonic 
and reconstructive properties of arsenic and strychnine are particularly 
desirable in lifting the patient into a condition where the normal process 
of the body will be taken up and carried on naturally. 



ENTERALGIA 561 

There is a current belief that strychnine is objectionable in spas- 
modic affections because in large doses it produces muscular spasm. 
This is a mistaken view. In spasmodic affections generally there is 
defective tone, not over tonus, as seems to be the idea; in other words 
the nervous system, being in a weakened and irritable condition, responds 
too readily to stimuli — because it is weak. Anything which serves to add 
tone and strengthen the control exerted by the nerve centers, minimizes 
the tendency to spasm; therefore strychnine meets an important indica- 
tion. But it should be given in small or tonic dosage, never in the large 
doses recommended in certain extreme cases where the full physiological 
action of the drug is required. 

Of course any intercurrent malady should be corrected. If there is 
splanchnoptosis, a suitable support should be worn and pelvic diseases, 
so common in these women, should receive suitable treatment. But 
these things I cannot well now discuss. 

ENTERALGIA 

Enteralgia: — Intestinal neuralgia may occur in the neurotic — hys- 
teric, hypochondriac, neurasthenic, cachectic or debilitated. Possibly 
it may be reflex, but the domain of this is being largely restricted by the 
recognition of autotoxemia as a cause of many maladies formerly inter- 
preted as reflex irritations. Spasm of portions of the bowel may be 
excited by the presence of foreign bodies or fecal concretions, parasites, 
or gas. Many cases believed to be intestinal colic are really due to gall- 
stones. Lead colic must .not be overlooked. 

Flatulence often precedes the occurrence of colic, which supervenes 
rapidly. The pain is severe, local or general, relieved by pressure, and 
may be excruciating. The most intense abdominal suffering is that due 
to the presence of large quantities of acid in the stomach and bowels. 
In hypogastric neuralgia the hemorrhoidal plexus is affected, as may 
occur with ataxia, hemorrhoids, or in female neuroses. The pain ra- 
diates to the sacrum, thighs and perineum, with distressing irritation of 
the bladder and rectum. 

The diagnosis is oftenest guessed at, but the relief from pressure or 
on evacuating gas, the absence of fever and evidences of local disease, 
the paroxysmal character, and relief following the use of relaxants, should 
suffice. Jaundice with itching skin, and hematuria, distinguish hepatic 
and renal calculi. Myalgia of the abdominal muscles is common and 
may be distinguished by the milder pain and the suffering felt when the 
affected muscle is put in contraction by faradism. 



562 NERVOUS DIARRHEA. 

Acids are quickly neutralized and the pain relieved by a teaspoonful 
of baking soda in a glass of hot water; or by a few grains of calx iodata. 
Spasmodic pain subsides under hyoscyamine and glonoin, gr. 1-250 each 
every five minutes, dissolved in hot water and allowed to be absorbed 
from the mouth, or given hypodermically. This prescription is im- 
proved by adding strychnine, gr. 1-134 to each dose, which aids in restor- 
ing the control of the nervous system over the spasmodic fibers. 

Any carminative, any mixture hot enough to bring the tears to the 
eyes, gives relief. Measures should then be taken to clear from the 
bowels any possibly irritating substances. 

NERVOUS DIARRHEA 

We have here a condition with no discoverable lesions, but morbid 
irritability of the bowel so that action is provoked by irritations incapa- 
ble of so acting in normal individuals. Three forms have come to 
the writer's notice. In lienteric diarrhea the taking of food quickly 
excites bowel action, the food being evacuated much in the condition 
in which it was swallowed. The patient may exhibit evidences of innu- 
trition with ravenous appetite. This is most common in rickety children 
and may precede the appearance of the characteristic symptoms of that 
malady. In all forms of this affection the writer has obtained most 
success from the use of artificial digestives, especially diastase, with minute 
doses of arsenic — copper arsenite gr. 1-1000 every one or two hours while 
awake. Predigested foods are useful as offering the best chance for 
speedy absorption. Sometimes it is well to give the stomach absolute 
rest and feed only by the rectum, vagina and skin for a week. The per- 
sonal and domestic hygiene always need to be carefully regulated. 

Chronic nervous irritability of the rectum with fecal incontinence 
existed in one case with a hereditary syphilitic taint, and recovered com-, 
pletely on specific treatment and colonic lavage. 

The third form may be exemplified by the following case: — A young 
lady while at a place of public meeting was seized with a sudden inclina- 
tion to evacuate her bowels, so severe that before she could find a toilet 
room an accident had occurred. This so impressed her mentality that 
from that day she had to give up church and all social intercourse. If 
a visitor was announced, as soon as she entered the parlor she would 
be seized with the inclination to go to stool and had to beat a precipitate 
retreat. By the time she had reached her toilet room the inclination 
might have subsided or not. This went on until she became practically 
a hermit, being excluded from everything that took her from her room. 



FLOATING LIVER 563 

She was well nourished, not at all neurotic otherwise, well educated, 
intelligent and in all other respects apparently in perfect health. After 
the lapse of years this malady was cured by suggestion. 

ENTEROSPASM 

Occurring primarily or secondarily to tubercular meningitis or lead 
poisoning, we rarely meet cases in which there is constipation from 
spasm of the intestinal musculature. The feces may be ribbonlike, or 
pipe stem, or in little bolls like sheep dung. Spasm of the rectum may 
accompany fissures, etc. The diagnosis is made by excluding organic 
strictures, etc., and recognition of the neurotic element. Treatment lies 
in excluding causes of nerve leakage and local irritation, and strengthen- 
ing the nerves generally. Copper arsenite or sulphocarbolate in small 
and frequent doses may prove effective. Try the latter, gr. 1-67 every 
two hours, with a soothing nervine like cypripedin, gr. 1-6 at each dose. 

All gastrointestinal neuroses respond to the ordinary treatment of 
depressed or exhausted nerves. Change of hygienic conditions, mental 
rest, means for restoring normal conditions of life and feeling, with the 
treatment of all material abnormalities, however trifling and apparently 
inconsequential, are advisable. It is impossible to lay down more defi- 
nite directions; each case demands the management appropriate to the 
conditions it presents. The man who treats all abdominal pains with 
codeine, and all nervous aberrations with bromides, misses a lot of the 
pleasure that comes from the pr :ctice of medicine. 

IX. DISEASES OF THE LIVER 

FLOATING LIVER 

Floating liver occurs ten times more frequently in women, following 
repeated pregnancies with too early escape from bed. Accessory causes 
are violent exertion, vomiting, coughing, sneezing, or falls. Lacing 
and rapid emaciation occasionally contribute. All these causes are 
far more frequent than this result. Pressure is not directly painful but 
may elicit pain in other parts. The traction may cause pain, especially 
after muscular effort or strain. Painful paroxysms may occur spon- 
taneously. The pains are generally relieved by some particular manipu- 
lation, or by pushing the liver into some easy position. The pain is felt 
in the normal location of the liver and may radiate to the right shoulder 
or the lumbar region. Bearing-down, colic, fullness, intestinal disorders, 



564 JAUNDICE 

fainting, and a belief in the presence of some living animal in the 
abdomen, may attend. Eructations, flatulence, gastric disorders and 
constipation, are also attendants. Various mechanical difficulties may 
be caused by the dragging, twisting and occasional compression of 
other organs, such as dyspnea, palpitation, ascites, hemorrhoids, met- 
rorrhagia, edema of the legs, albuminuria, purpura, polyuria, and 
rarely jaundice. Repeated hematemesis was reported in one case. 

Palpation and percussion show the liver in an abnormal situation 
and its absence from its ordinary place. Easy replacement when lying 
supine in significant. The liver always seems large. Diagnosis may 
be impossible until tapping. Mistakes have been caused by the presenoe 
of a thickened mesentery; and the. liver has been mistaken for hydro- 
nephrosis, floating kidney, renal tumor and typhlitis. 

Treatment: — The lost abdominal tone may be supplemented by an 
elastic bandage, and possibly restored by faradic massage, cold douches, 
and suitable exercises. Since berberine restores contractility to relaxed 
connective it should be given in full doses to toleration for months. 

JAUNDICE 

The slighest obstruction to the flow of bile in the biliary passages 
suflices to cause reabsorption. Bile appears first in the urine, and within 
12 hours in the skin, preceding this in the conjunctiva. Its color is 
imparted to the blood plasma, serum of blisters and exudates^ cerebro- 
spinal fluid, the connective tissues selectively, less to the nervous and 
muscular tissues, slightly to the glandular and epithelial cells except the 
rete Malpighii and kidney, and the fetus. The pigment is excreted by 
the kidneys, causing degeneration of the epithelium and occlusion of 
the uriniferous tubules. Pus contains bile but no mucous secretions 
except that of the intestines. Milk and pneumonic sputa are rarely 
colored, saliva never. The color of the skin varies from lemon yellow 
to bronze. The itching is not due to bile but to the elimination by the 
skin of toxic matters formed in the bowel. The presence of bile in the 
urine is detected by adding to it a drop of commercial nitric acid, on 
a porcelain plate, when a play of colors is seen. The stools are dark 
if the diet be of meat, putty-like otherwise; and are generally very offen- 
sive. Constipation and flatulence are present. The blood becomes 
toxic and intense jaundice induces coma that may be fatal. 

Jaundice may be caused by emotion, it may occur in pregnancy or 
menstruation, fasting, or be due to syphilis, affects 15 to 85 per cent of 
newborn infants, follows large extravasations of blood, hemoglobinuria 



CATARRHAL JAUNDKT. 565 

or any poison that dissolves red cells and may he due to excessive produc- 
tion of bile. It may follow anesthetics, accompany acute infections, 
and occurs in epidemics. 

CATARRHAL JAUNDICE 

Etiology: — This is usually an extension of catarrh from the duodenum 
and stomach, hence results from over-eating, or the use of unwhole- 
some food, cold drinks, or alcohol to excess. Chronic alcoholism pre- 
disposes. The acute attack may follow exposure and catching cold. 
Previous attacks establish predisposition, and so also do hyperemic con- 
ditions of the liver. The cause cannot always he discovered. Catarrhal 
jaundice occurs in the course of infections, such as malaria, typhoid 
fever and cholera; in phosphorus poisoning, calculi and other obstruc- 
tions. The disease occurs more frequently in young men. 

Symptoms: — Following a catarrh of the stomach with digestive diffi- 
cult' es, headache, dizziness, depression and sometimes fever, constipa- 
tion and scanty, high-colored urine, the eyes, skin and urine begin to 
show the yellow tint; the feces become light and offensive. This may 
persist for one or two weeks. When the digestive symptoms subside, 
color returns to the stools and disappears from the urine, that of the 
skin persisting longer. Convalescence is apt to be prolonged. 

To this typical course there are many exceptions: Jaundice may 
be the first symptom manifested; the obstruction may be intermittient; 
the pulse is slow; there may be pressure in the liver, which may be 
swollen as well as the spleen; the urine contains bile, urobilin, hyaline 
casts, some times albumin. After the first week the temperature is a 
little subnormal. Itching is usually most violent after the first few days. 
Abortive forms are brief and mild. Sometimes the malady lasts for 
months, with exacerbations from indiscretions in diet or otherwise. 
Intercurrent febrile attacks may be ascribed to infectious invasions. If 
the attack persists for some weeks the digestive symptoms subside, while 
depression and debility increase, with emaciation from hepatic auto- 
intoxication. Sometimes the attack resembles typhoid fever, with severe 
gastric symptoms, aching of the head and limbs, marked depression, 
insomnia, chills and high fever, enlargement of the spleen and other 
evidences of general infection. The liver may be tender and enlarged; 
the fever intermittent; and in its tedious course and subsidence the 
resemblance to typhoid fever may be close. 

Recovery may be incomplete, with recurring acute attacks, or calculi 
may form as a result, or suppuration of the ducts. The disease may 



566 INFECTIOUS CHOLANGITIS. 

persist in the cystic duct and gall-bladder. Chronic inflammations of 
the hepatic tissues, cirrhosis, and rarely acute yellow atrophy may follow. 

Anatomy: — The epithelial layer is destroyed, and a secretion of mucus 
occurs containing leucocytes. Mucous plugs may occlude the common 
duct. The walls may be stained with bile. The degree to which 
bacteria contribute their influence is not yet determined. Toxin absorp- 
tion from the bowels complicates the clinical picture. 

Diagnosis: — Typical cases are easily recognized. In others jaundice 
may mask an underlying disease, as in gallstones and compression. The 
history and course must be scrutinized, the patient's youth considered, 
and the previous existence of gastrointestinal catarrh. 

Prognosis: — The prognosis is good, but the duration of the attack 
cannot be predicted. Acute febrile cases continue several weeks and 
seriously impair the strength and nutrition. Mild, incomplete cases 
are exceedingly irregular. Elderly patients may die from long-con- 
tinued obstruction. 

Treatment: — Empty the bowels with calomel, followed by salines 
and repeated enemas, preferably of cold water thrown into the colon. 
Strictly limit the food to hot liquids. Give sodium succinate, 5 grains 
every six hours; boldine, gr. 1-67 every two hours; chionanthin or dios- 
corein, gr. J, every two hours; The benefit resulting from each of these 
remedies appears to be unmistakable, but we are not as yet able to dis- 
tinguish the cases in which each should be selected. The free use of 
water is advisable. The patient should be kept quiet. If the attack 
is due to catching cold, diaphoretics are indicated, and of these the 
most effective is pilocarpine, which is also a specific for the itching. The 
diet should be carefully watched during convalescence. Nitromuriatic 
acid has long enjoyed a reputation which cannot be altogether unde- 
served. The strong acid only should be used, in doses of five drops, 
well diluted, before meals. Most of the remedies that have acquired 
repute in the treatment of jaundice act simply by clearing out the alimen- 
tary canal and putting a stop to intestinal toxemia. The four remedies 
mentioned above, however, seem to exert a special effect in subduing 
catarrhal inflammation of the biliary passages. 

INFECTIOUS CHOLANGITIS 

Suppuration is much less common in the biliary passages than catarrh. 

The disease is rare, and occurs in elderly persons with some obstruc- 
tion to the discharge of bile, or complicating dysentery, typhoid, septi- 
cemia or cholera. The source of infection can not always be traced. 



INFECTIOUS CHOLANGITIS 567 

The invading organisms may not cause any disease appreciable during 
life, or even at post mortem. The most frequent infective agent is 
bacillus coli, alone or with various cocci. Ascarides may occasion the 
attack by carrying microorganisms into the biliary passages. Typhoid 
fever is the malady most frequently complicated with infective cholan- 
gitis, and the bile often contains bacillus typhosus, even months or years 
after convalescence has commenced. Implication of the biliary pas- 
sages may account for the jaundice sometimes present in pneumonias. 

Symptoms: — These are uncertain and not characteristic. Jaundice 
is not marked and is due to obstruction, which is not always present, 
or may not be due to infection, Fever and swelling of the spleen are signifi- 
cant, the former of septic, sometimes of malarial type. Gall-stones may 
complicate the picture. Other toxins absorbed may depress the heart, 
lower the temperature, or stimulate the kidneys. There may be pain 
or tension in the liver, especially severe if the gall-bladder is inflamed. 
Digestive disturbances, diarrhea and vomiting are frequent. Leucocy- 
tosis is absent in the intervals, and the excretion of nitrogen by the 
kidneys is diminished on the febrile days. Tenderness near the spinous 
process of the 12th dorsal vertebra has been found by Boas. Occasional 
complications are pylephlebitis, true septicemia, endocarditis, suppura- 
tive meningitis and peritonitis. 

The course is insidious and variable. Occurring during the course 
of a specific infectious fever the symptoms may be incon- 
spicuous; little if any jaundice, fever and tension. Coming on during 
convalescence from typhoid fever we may apprehend a reinfection of 
the bowel. 

The prognosis is not good. The dangers of calculi are increased by 
abscess formation. Ulceration is most common in typhoid infections. 
The discharge of a calculus is favorable. 

The diagnosis may be made when to the evidences of gall-stones we 
add a fever of septic or remittent type, with progressive debility. Doubt- 
ful cases may be distinguished by a careful study of the temperature 
curves. Pyemic fever reaches its acme after noon. The presence of 
leucocytosis, or of pigment and plasmodia in the blood, indicate malaria. 
Local symptoms place a suppurative malady in this region. In hepatic 
abscess the jaundice is less evident, and the previous history varies. 

TreBtment: — The occurrence of such infections emphasizes the import- 
ance of maintaining intestinal antisepsis throughout attacks of infectious 
fevers. The remedies that have proved efficacious in gall-stone will 
probably be found to favorably influence this malady as well; and should 
receive full trials. Digestive disturbances may be prevented by the use 



5 68 CHOLECYSTITIS 

of the salts of bile acids. Ascarides should be expelled from the bowel. 

Five grains of sodium succinate, boldine, gr. 2-67, dioscorein aridchio- 

nanthin aa, gr. 1-3, four times a day may be taken as a commencing 

adult dose. The pains may be alleviated by hot enemas, and by hyos- 

cyamine given till effect. The diet should be carefully regulated, and 

milk has been most highly recommended. Give it warm, eaten slowly, 

a glass every four hours, and no other food whatever. 

Other means at our disposal are saturation with calcium sulphide, 

a remedy which is indicated in all pus infections, wherever located, and 

nuclein medication. 

f) \o gnrlb oval . 

■ 
>d 9iii ezaiqsh '/sun I LklULhL loLLLlo 

When the biliary passages are inflammed the gall-bladder is usually 
implicated if not always. The same causes are therefore present as 
in cholangitis. The mucosa is inflamed the mucous secretion increased, 
thickened by epithelium cast off, and the narrow outlet becomes occluded. 
The bladder dilates and its walls become hypertrophic and finally cir- 
rhotic. Peritoneal adhesions forms. When the contents are absorbed 
or discharged the sac contracts, or its walls may calcify. Corsets fre- 
quently give rise to this malady. Gall-stones are frequently present. 
Suppuration is not common. Distention may lead to ulceration, espec- 
ially in typhoid cases, sometimes forming fistulas. 

The pain is inflammatory, severe if the serosa is involved and in acute 
attacks, increased by motion, distention or peristalsis. The distended 
gall-bladder forms a tumor recognized by its shape if not obscured by 
surrounding lesions, or by tension of the abdominal parietes. It is 
pear-shaped, and moves with the liver and with respiration. Fecal 
collections and appendicitis may simulate it, or corset liver. All grades 
as to acuteness and length of course are possible. The pain and swell- 
ing are apt to be worse if suppuration occurs, the continuous fever chang- 
ing to the septic type. Cutaneous edema may attend adhesions. 

The diagnosis must frequently be inferential. 

Confine the patient to bed, restrict the diet to unirritant fluids, and 
restrain peristalsis and spasm by full doses of hyoscyamine, gr. 1-250 
every fifteen minutes to an adult until the mouth begins to feel dry, 
then another dose whenever this ceases. Leeches, cold or heat, over 
the affected viscus, give relief — the choice lies with the patient's prefer- 
ences or the effect. The lower bowel must be kept empty by colonic 
flushing with warm saline solutions. Give a course of sodium succinate 
as described above. 



GALL-STONES 569 

GALL-STONES 

h 

Gall-stones are composed mainly of cholesterin, bilirubin-calcium 
and calcium carbonate, in varying proportions. 

Their shape depends on their location and number. Single stones 
are rounded or oval, multiple ones are facetted by contact with each 
other. The sides next the mucosa are rough, those facing other stones 
smooth. 

The size varies from mere sand up to masses several inches long and 
wide, and several ounces in weight. 

Etiology: — Gall-stones are formed by the deposit of their elements, 
from the bile, upon a nucleus. Naunyn found myelin from fatty degen- 
eration of epithelium formed the mucleus, surrounded by a shell of 
lime salts, or a soft shell of cholesterin and bilirubin-calcium, with a 
fluid center. Calcic stones form in the bile ducts, with pigment whose 
oxidation Naunyn attributes to bacteria. The subsequent deposits are 
cholesterin pure or with lime salts. The infiltration and recrystalliza- 
tion of cholesterin accounts for the radiated structure. Contraction 
and expansion, with the solvent action of bile, sometimes cause spon- 
taneous cure^ The primary cause of biliary calculi is therefore catarrh 
of the biliary mucosa. The catarrh is attributed to bacteria. Micro- 
organisms have been found in recently formed calculi, most frequently 
typhoid and colon bacilli. Stasis of bile favors infection. When germs 
are virulent, acute cholecystitis results; if attenuated, cholelithiasis if the 
outflow is obstructed. The latter condition is especially favored by 
the corset and by pregnancy, hence the greater prevalence of gall-stones 
in women. Sedentary habits also favor the formation of calculi, as 
do mitral and other obstructive valvular diseases, and all conditions 
favoring indigestions. The prevalence increases constantly with age. 
Some localities seem to be affected more than others. 

Pathology: — Gall-stones have been found in autopsies in from 2.4 
per cent to 29 percent. Mosher in Baltimore found them in 6.04 per 
cent. Poulson says symptoms during life are only presented by 8 per 
cent of cases. The number of stones varies from one up to Otto's 7802. 
The stones may be encysted or free. The gall-bladder is enlarged, or 
contracted, catarrhal, ulcerated, adherent, cystic, hypertrophic, trabecu- 
lated, cicatricial, dropsical, diphtheritic, ecchymotic, necrotic or per- 
forated. Similar changes occur in the gall-ducts. Secondary changes 
occur in the hepatic parenchyma. Multiple abscesses may form, or 
suppurative cholangitis, pylephlebitis, or portal thrombi. Fistulae may 
penetrate the skin, peritoneum, diaphragm, intestines, pleura, lungs, 



570 GALL-STONES 

etc. Carcinoma is a result, not a cause of gall-stones (Quincke.) The 
calculus may migrate to the iliac fossa, the female genitals, the urinary 
bladder, etc. If a large stone enters the small intestine it may cause 
obstruction at the ileocecal valve, or in the duodenum. It may enter 
the appendix. The bacteria sometimes cause endocarditis. 

Symptoms: — In the vast majority of cases the malady is not suspected 
during life. Usually the first symptom is caused when the stone enters 
the duct, when it excites inflammation or ulceration, or when it blocks 
the passage of bile and infection ensues. 

Prodromes consist of intestinal catarrhs, especially duodenal, which 
may extend to the bile ducts; or of catarrhal jaundice alone; but no 
such malady precedes in many cases, and the first symptom attributable 
to cholelithiasis is the attack of colic. Some patients complain of epi- 
gastric weight, altering its location with changes of posture, worse after 
sitting or standing for . long periods (probably myalgic) and near the 
close of gastric digestion. There may be dull pain in the right epigas- 
trium, radiating to the right shoulder, thorax, hypogastrium or lumbar 
region. The appetite may be capricious, anorexia alternating with 
gluttony. Slight errors may cause nausea and bilious vomiting. The 
nervous condition is low, with irritability and depression, itching or 
burning. There may be disturbances of sight or hearing, coryza, head- 
ache, neuralgia and other indications of a leakage of nerve force, with 
"reflex" phenomena at the point of least resistance. The digestive 
secretion may be excessive or scanty. These patients dislike laxatives 
and these may occasion abdominal distress. 

Very rarely the stones may be recognized on palpation. Some have 
even heard the stones rattle ! 

Calculi in the hepatic ducts are usually latent, rarely causing inflam- 
mation or jaundice. In the cystic or common duct they are usually 
movable and cause trouble. Even then there may be no pain, as gall- 
stones may pass without having occasioned any previous symptoms. 
More frequently hepatic colic results. Stones may be impelled to move 
by violent exercise, over-eating or drinking; delivery; surgical operations; 
menstruation; psychic crises, etc. Contraction of the muscular fibers 
of the gall-bladder forces the stone into the cystic duct where it is firmly 
grasped by the irritated fibers of the muscular coat and held spasmod- 
ically until, the irritability of the fibers being exhausted, they relax and 
allow the stone to slip forward until it is grasped by a new set. Irrita- 
tions of the duodenal or gastric musculature may be transmitted to the 
gall-bladder. If the stone is large in relation to the lumen of the duct, 
considerable time may be required before the dilatation suffices for 



GALL-STONES 571 

its passage. The tortuous course of the duct and its twisted, folded, 
mucous coat aid in obstructing the passage of the stone. The common 
duct being wider, the course is more rapid, but delay is occasioned by 
the sphincter at its outlet. Indeed, the stone may be permanently 
arrested here. When the stone drops into the duodenum the spasmodic 
pain ceases at once. The size and shape of stones influence the rate of 
passage, but even very small ones excite spasmodic contractions, and 
smooth stones quite as much as rough ones. Calculi too large to pass 
through the ducts remain in the gall-bladder or biliary ducts, or escape 
by ulceration. Soft stones may be molded or crushed by the pressure. 
Contraction of voluntary abdominal muscles may aid, but increases the 
pain. Vomiting exercises a similar influence, and the relaxation it 
causes lessens the principal obstacle — spasm of the ducts. 

The attack may begin with pain and a sense of pressure in the epigas- 
trium or at once with violent colicky pain, usually in the afternoon or 
during the night. The pain is boring, stabbing, tearing, persistent and 
unbearable, the patient groaning heavily, shrieking, crying, or some- 
times silent, collapsed, the face pallid, lips blue, eyes sunken, covered 
with cold sweat, extremities cold, pulse wiry and small. The pain is 
often in the region of the gall-bladder, but may be in the epigastrium, 
left hypochondrium or breasts, and radiates in all directions. It may 
be in the back, simulating renal colic. Epigastric pain locates the stone 
in the hepatic ducts. Inspiration is painful and the breath- 
ing is rapid, shallow and costal. Patients twist the body to the right 
and draw up the legs, to relax the right abdominal muscles. Rigidity 
and spasms are not uncommon here. Temporary remissions may occur. 
When the stone enters the common duct there may be a pause or the 
pains may be easier until the sphincter is reached, when the severe 
cramps recur. If the stone drops back into the gall-bladder the pains 
cease as abruptly as when it falls into the duodenum. Much soreness 
remains, with a bruised sensation. Tenderness in the gall-bladder 
indicates that the stone has fallen back. The suffering seems less in the 
aged w r hose irritability is less, and when the ducts have been dilated by 
repeated passage of calculi. The vomiting is apt to be violent; at first 
of food, then of bile, and sometimes the calculi are thus ejected. Chills 
or rigors may occur, and fever develop, which subsides in some hours 
or endures several days, as the stone passes. Even without septic infec- 
tion it may be intermittent. Lodged in the ampulla of Vater, a stone 
may cause recurring febrile attacks with pain and jaundice, acting as 
a ball-valve. Some infection is apt to follow. In fact, to this a part 
at least of the fever may be attributed in all forms. 



572 GALL-STONES 

Jaundice is usually but not always present; as when the obstruction 
is in the cystic duct, when it does not occlude the common duct, when 
it passes the latter too rapidly for reabsorptive back-pressure to develop, 
and when it has left the biliary passages and formed a fistula. If a 
small hepatic duct is occluded there may be no apparent jaundice, but 
traces of bile may be detected in the urine. Time must be allowed for 
collection and reabsorption of bile before jaundice appears — perhaps 
some days. It persists as long as obstruction of the biliary ducts endures. 
The intensity of the color varies. The urine is reddish yellow to black. 
The bilirubin may be detected here before the skin shows color change. 
The greatest impregnation of the urine occurs when the obstruction ceases 
and the stored bile passes at once into the duodenum, the pigment being 
rapidly converted into urobilin and excreted as such. 

Search should be made for the stones by passing the feces through 
a hair sieve for several days. Failure to find the stone may be due to 
its dropping back into the gall-bladder, its retention in the biliary pas- 
ages, or in the common duct, or its disintegration. 

Stones less than a hazel-nut in size pass through the ducts in time; 
larger ones become impacted and if freed at all it is by ulceration. 

When the attack has subsided it leaves debility, anorexia, disturb- 
ances of digestion and nutrition, and insomnia. But the most dis- 
tressing sequel is the itching. During the greatest severity of the par- 
oxysm the patient has adjured the physician to prepare for combating 
the itching which would follow, as she knew by experience. Death 
rarely ensues from the toxemia or from the failure of the nervous system 
to bear the suffering. 

Since only about one person in twelve of those who carry gall-stones 
even presents a recognizable attack, we may look for evidences of these 
calculi in any anomalous abdominal malady. The detection of a 
trace of bile in the urine is then significant, though not conclusive. 
Not all attacks are as severe as those described and many may be 
abortive. 

Complications: — Infective cholangitis and cholicystitis; hepatic 
abscess; ulceration; stricture; encapsulation; permanent occlusion of bile 
ducts followed by many consequences; lesions of tissues invaded by the 
ulceration; obliteration of the gall-bladder; hydrops vesicae felleae; per- 
manent jaundice; cholemia with furuncles, hemorrhages, cirrhosis, coma, 
enlarged spleen, ascites; carcinoma. If the bile does not find an outlet 
into the intestine death results in six to twelve months. Impacted in 
the bowel, gall-stones may be dissolved or disintegrated, or form the 
nucleus of fecal masses. 



GALL-STONES 573 

The vomiting of fecal matter indicates the low location of the 
obstruction. Attacks of ileus are common. Death ensues from exhaus- 
tion and collapse, rarely from peritonitis. In protracted cases anemia, 
debility and emaciation occur. Many nervous phenomena have been 
described. Hemorrhagic pancreatitis was found in one case by Opie, 
bile having entered the pancreatic ducts. *.1n3inlB3lT 

Prognosis: — While there is always danger, the prognosis is good. 
Violent fever, total obstruction, peritonitis, infective attacks and sup- 
puration, are grave. Peritoneal perforation causes imminent danger. 
Impaction in the bowel, grave tissue alteration in the liver, ascites, 
collapse, marked debility, anemia or emaciation, and the development 
of cancer are ominous. 

Diagnosis: — Rarely, when the stones are quiet, physical examina 
tion may detect them. The presence of a trace of bile in the urine 
always indicates obstruction and reabsorption. Lanphear says that 
gall-stones may be assumed in any person over 45, with pendulous 
abdomen. The enlarged gall-bladder is attached to the liver, moves 
with respiration, is freely movable, but returns to its place. It cannot 
be pushed upward (Gerard-Marchand). Puncture and rude palpation 
are perilous. Gall-stones cannot be detected by the x-ray, which 
traverses cholesterin. 

Colic is usually the first evidence. In peptic ulcer the pain follows 
meals; in gall-stones it occurs near midnight; violent vomiting is seen 
rather in the latter. In intestinal colic the pain is in the right hypochon- 
drium, is less severe, and. is relieved by discharges of gas, or feces. 
Lead colic presents similar attacks, but is more common in men who 
have used the metal; the blue line on the gums, absence of liver symp- 
toms and jaundice, are notable. Renal colic is felt in the lumbar region, 
along the ureter, and the testicle may be retracted. Circumscribed 
peritonitis has its own causal history -and no hepatic symptoms, but 
tenderness, quick pulse and early collapse, with costal respiration, and 
indoxyl in the urine instead of bile. Jaundice is a most important sign, 
and by its variations affords an insight into the progress of the attack. 
The presence of infectious agents may be determined by studying the 
temperature. Hepatic abscesses are often unrecognizable. Tender- 
ness of the liver, pyemia, septic fever, and secondary suppurations, may 
indicate their presence. 

The final proof is the detection of the calculi in the stools. 

Prophylaxis: — To prevent cholelithiasis we must prevent stasis of 
bile and infective cholangitis. Tightness of clothes over the liver, corset 
pressure, especially in the thin, sedentary habits, conduce to the malady. 



574 GALL-STONES 

Exercise and cold bathing aid in preventing it by favoring the move- 
ment of bile. Constipation calls for saline laxatives. Several observers 
warn against going too long without meals. Too uniform a diet and 
excess of fat are to be avoided. Infections of the stomach and bowels 
are always capable of affecting the biliary passages. 

Trestment: — Basing our treatment of the paroxysm on the spasmodic 
character of the pain, we seek to relieve this by the administration of 
the speediest of antispasmodics, glonoin. The brevity of its action 
necessitates the addition of hyoscyamine by which the effect is prolonged, 
while by relaxing the contracted vessels glonoin permits the hyoscya- 
mine to enter and develop its effects more speedily. Looking upon all 
spasm as an indication of deficient nervous control we add minute doses 
of strychnine to restore the supremacy of the controlling nerves. Our 
prescription for an adult is therefore: Hyoscyamine, glonoin, aa gr. 
1-250; strychnine arsenate, gr. 1-134, to be given together and repeated 
every ten minutes until dryness of the mouth indicates the full desir- 
able action of hyoscyamine. If this does not render the suffering bear- 
able a mere whiff of chloroform or ether will suffice to complete the 
relief. So certain is this treatment that we may rest assured that when 
it fails there is present a mechanical condition whose relief is only to 
be secured by mechanical intervention. These remedies are best admin- 
istered each in a teaspoonful of hot water, to be absorbed from the 
mouth. If the gastric irritation is too great, a full dose may be given 
by hypodermic; though the intensive small-dose method, is in every 
way more desirable. The usual method of treating the paroxysm is by 
the hypodermic injection of morphine. This is not as powerful an anti- 
spasmodic as hyoscyamine, and as an analgesic its effects are neutral- 
ized by the pain. The doses are repeated, increased, and at last, impelled 
by the prayers of the patient for relief from her excruciating suffering, 
a huge dose is given. Just then the stone rolls into the duodenum, the 
antagonism exerted by the pain ceases, and the patient experiencing 
the whole force of the morphine is narcotized, perhaps fatally. 

Quite recently reports indicate that the new anesthetic tablets of 
morphine, gr. 1-4, hyoscine hydrobromide, gr. 1-100, and cactin, gr.. 1-67 
excel anything as yet tried in relieving these agonizing paroxysms. The 
method seems as safe as it is effective. 

Is there any treatment that will prevent the recurrence of the par- 
oxysms? The surgeon denies this, demanding proof that any remedy 
proposed will, in the body, cause solution of the calculi. The fact that 
in over 90 per cent of all cases the stones never occasion enough distress 
to lead to the suspicion of their presence, would indicate that the removal 



(.ALLS TONES 575 

of the stones is not a necessity. Moreover, the acknowledged solution 
by the bile that sometimes occurs points to the possibility of this solution 
being favored by remedial agents. The production of an abundance 
of thin, highly alkaline bile, with great solvent power, the cure of biliary 
catarrh and extinction of infection in the biliary passages, as well as in 
the duodenum, are legitimate objects of medical treatment. 

For twenty years the writer has treated every case of supposed cho- 
lelithiasis that has come to him in a somewhat extensive practice in the 
manner to be described. Admitting that the diagnosis may have been 
mistaken in some instances, he would submit that the assumption that 
in that period he never saw a true case of this disease, but was always 
mistaken, is scarcely to be seriously held by any but a purblind advocate 
of the " no-treatment-but-surgical- " dogma. The treatment adopted 
consists in the administration of sodium succinate, gr. 5 four times a 
day, before meals and at bedtime. This is to be continued for one year. 
During this period the paroxysms become progressively less severe and 
less frequent, until long before the expiration of the year they have 
entirely ceased. This happy result has followed in every case treated 
by the writer with this remedy in twenty years. In not one has surgical 
intervention been required. Nevertheless, we are not bigoted opponents 
of surgery, and as above stated urge a prompt resort to it whenever the 
failure of the treatment for the paroxysm above advised indicates the 
presence of mechanical conditions in which surgical intervention is pre- 
ferable, even if not absolutely necessary. 

In France boldine has acquired so great repute as a systemic remedy 
for this malady that we have felt obliged to advise its use in addition 
to the succinate of soda, giving of boldine seven milligrams a day for 
prolonged periods. It has seemed to the writer to be distinctly effective, 
in a similar manner to the succinate, and the results obtained to be 
more rapidly induced by the combination. Among the Eclectics dio- 
scorein in the paroxysms and chelidonin in the intervals have won favor 
too universal and decided to be without value. Dioscorein may be given 
in hot water, gr. J to J every ten minutes; the dose of chelidonin is a 
grain a day, in divided doses. These remedies may be added to those 
above recommended if deemed advisable; or employed in the absence 
of the former. 

Heat to the feet, counterirritants over the liver, supportive foods 
and medicines, may be employed as adjuvants during the paroxysms. 
Hot enemas are probably useful. The bowels should be emptied. 

In the intervals constipation should be carefully avoided and gastro- 
duodenal catarrh relieved. Copper arsenite, gr. 1-67 before meals, is 



576 GALL-STONES 

useful, and five to twenty grains of sodium sulphocarbolate may be given 
with each dose of the succinate. Mineral waters are useful as diluents, 
and in proportion to the soda they contain. The diet should be nutri- 
tious, easily digested, taken at regular intervals, and in just " dose- 
enough," neither too much or too little. Excess of fats, ices, iced bever- 
ages, beer, alcohol in general, tainted or infected foods, are to be for- 
bidden strictly. The patient should wear wool next the skin and avoid 
taking colds. Judicious exercise and bathing contribute to the pre- 
vention of attacks. 

The itching of the jaundice is quickly relieved by a dose of pilocar- 
pine sufficient to induce sweating-— gr. J hypodermically. 

The ingestion of fats has no effect on this disease, excepting in so 
far as they relieve the constipation on the one hand, or induce digestive 
disturbances on the other. Quincke advises meals every three hours, 
to stimulate the production of bile. Too sparing a supply of water 
leaves the bile too thick for solvent power. Lime in food or water does 
not favor the growth of the stones. There is no plausible indication 
for any form of electricity. The value of vegetable extracts was inferred 
from Glisson's observation that in cattle gall-stones seem to disappear 
when the winter has passed and green forage is accessible. Olive oil 
in large daily doses keeps the bowels open but has no other effect, the 
apparent calculi voided during its use being composed of soap derived 
from the oil. Ice over the gall-bladder may give some relief. Some 
patients are easy while immersed in a warm bath. If the bowels must 
be evacuated and the stomach rejects everything, a cold enema of saturat- 
ed salt solution acts promptly. ^^ 

Operation is advised by Quincke at once if suppurative cholangitis 
or cholanystitis, or incipient peritonitis, appears. Salicylic acid has proved 
an effective remedy to disinfect the biliary passages, and sodium succi- 
nate probably acts also in this way. Operation is perilous in prolonged 
jaundice, as hemorrhage is apt to follow. 



Hyperemia of the liver occurs during digestion. Congestion attends 

obstructive heart diseases and pulmonary maladies. The former may 

be carried to pathologic degree by excess in eating and drinking, alcohol, 

etc., and by fecal toxins absorbed; also by infectious fevers, suppressed 

menstruation, etc. It causes a sense of fullness and aching, increased 

by motion or lying on the right side. 

Hepatic hemorrhage is a feature in many maladies. 

Perihepatitis in various forms attends many hepatic maladies, or 
may be induced by corset pressure. 



r ABSCESS OF THE LIVER 577 

Acute HepBtitis accompanies infectious fevers, due to toxemia, and 
may be caused by a number of poisons. It occurs also in northern men 
residing in the tropics. The treatment consists in emptying and dis- 
infecting the alimentary canal to stop toxin absorption, regulating the 
diet and personal hygiene, and return to the cooler latitudes if this is 
possible. 

Acute Btrophy of the liver occurs rarely, in women between 20 and 
30, during or following pregnancy; more rarely under other circum- 
stances. The causes are obscure. Quincke suggests intestinal and 
bacterial toxins. The attack begins as an acute catarrh of the stomach and 
duodenum, passing to the biliary passages. Suddenly evidences appear of 
profound toxemia, stupor, delirium, restlessness, mania, rapid shrink- 
ing of the liver and swelling of the spleen, hepatic pain, hemorrhages, 
from all sources, subnormal temperature, and death in a few days from 
coma. The hepatic substance is destroyed, but in cases recovering is 
rapidly regenerated. Jaundice is intense, with tender liver, vomiting, 
constipation, slow pulse and convulsions especially in the young. Half 
die within two weeks, one-third more before the fifth week. Recovery 
is possible. 

The malady is obscure — a swift local poisoning with an unknown 
toxin. It resembles phosphorus and phallin poisoning, and acute fatty 
degeneration. Quincke pronounces it a purely chemic poisoning, the 
toxin generated in the bowel, part of the symptoms due to cessation of 
liver detoxication. The diagnosis is never made until the grave symp- 
toms are presented, when decrease of the liver is detectable, with leucin 
and tyrosin in the urine, with intense jaundice, etc. 

Prevention indicates the wisdom of flushing and disinfecting the 
bowel in every case of catarrhal jaundice, and in pregnancy (Quincke), 
and examinations of the urine. The only treatment that has succeeded 
is free purgation, with warm baths to favor elimination and quiet rest- 
lessness. 

Abscess of the liver is occasioned by bacterial invasions, sometimes 
carried by parasites. It may be traumatic, without penetration. 
Suppuration along the gastrointestinal canal furnishes most cases, some 
coming by the hepatic artery from the heart, etc. They are more fre- 
quent in men, and in the tropics, except when due to appendicitis. 
Uteroovarian suppuration contributes some cases, and operations on 
hemorrhoids a few. 

The symptoms are cachexia, despondency, anemia, fever remittent 
or continuous, of septic type, pulse small and weak, and the typhoid 
state with stupor. There may be much, usually little, sometimes no, 



578 CIRRHOSIS OF THE LIVER 

local inflammatory trouble manifested. Pain is prominent if the surface 
is affected. Partial enlargement occurs when the abscess projects from 
the surface. Intrusion on other organs causes characteristic symptoms. 
The abscess may discharge through the skin, diaphragm, into the pleura, 
bronchi, lung, stomach, bowel, bladder, or peritoneum. 

The prognosis is worse in pyemia, portal infections and traumatic 
cases; better in non-virulent forms, tropical abscesses and when operation 
is performed early. The x-ray may aid the diagnosis. The pus 
obtained by aspiration may be bloody or fetid. 

Prophylaxis demands the antiseptic treatment of dysentery and 
other gastrointestinal infections, while sulphide saturation may prevent 
or abort suppuration, aided by nuclein, and the resisting powers are to 
be maintained at the highest point. Ice over the liver and leeches to 
the perineum relieve pain and hyperemia. Relief has been obtained 
from hepatic punctures with abstraction of blood directly from the liver. 

CIRRHOSIS OF THE LIVER 

Etiology: — The most common of hepatic maladies, one whose 
causes, course and treatment are best comprehended. It occurs mostly 
in men, after mid-life, habitual users of strong liquor. Periodic 
debauches do not occasion cirrhosis, but the daily use of strong liquor, 
taken "straight," on an empty stomach. A man may never have been 
intoxicated and yet have a cirrhotic liver. It is probable that the addi- 
tion of volatile oils increases this tendency, hence the danger in " cock- 
tails. " Syphilis comes next to alcohol as a cause, then malaria and possi- 
bly typhoid fever, cholera, scarlatina, gout, rickets, etc. Several factors 
act together. In some the cause cannot be traced, and these may be 
attributed to toxins of intestinal origin, or to microorganisms which 
resist the destructive action of the liver. There is also an individual 
vulnerability to this disease and a hereditary disposition. 

PBthohgy: — The cirrhotic liver is small, surface studded with "hob- 
nails," over which the serosa is thick. The connective tissue is hyperplastic 
and its growth and contraction causes destruction of the liver cells. The 
white fibrous tissue increases and elastic fibers are also formed, both 
penetrating the lobules. In the reticulum the process is hypertrophic 
rather than hyperplastic. Sometimes the surface is smooth, but shows 
similar microscopic changes. The process is of many years' duration. 
The hepatic cells are destroyed by pressure and by cutting off their 
blood-supply, the protoplasm first becoming fatty. Portal stasis results 
from destruction of the capillaries. 



CIRRHOSIS OF THE LIVER 579 

Symptoms: — The primary hyperemia caused by alcohol being repeated 
with every dose is not a single process confined to a certain period and 
to be recognized by symptoms. It is in fact continuous and inextri- 
cable from its later consequences. We have in some cases the alcoholic 
dyspepsia with morning nausea, anorexia, and growing inability to 
digest food without the accustomed stimulant, and later even with it. 
The steady drinker tends to become sparing in his diet and to choose 
such foods as are digested most readily; also to consume large quantities 
of condiments, such as red pepper, mustard and horseradish. Occa- 
sional attacks of pain in the liver may be due to hyperemia from these 
substances, or to intestinal toxemia. As a rule nothing calls attention 
to the liver during the period of enlargement. The organ is firm and 
somewhat sensitive. Reduction in its size is not easily determined by 
percussion unless extreme. Palpation may detect nodulations in the 
later stages. Jaundice is slight or absent. Destruction of the capil- 
laries leads to obstruction of the portal circulation and the blood is 
engorged in its roots, inducing fullness of the capillaries of the stomach, 
intestines and spleen. Catarrh of the mucosa follows, with anorexia, 
diarrhea, hemorrhoids, enlargement of the spleen, and hemorrhages 
from the mucous surfaces. When the engorgement reaches a certain 
point the serum transudes into the peritoneal cavity and ascites results. 
Constipation, flatulence, indigestion and difficulty of absorption into 
the distended vessels induce innutrition. Collateral channels open in 
the liver and the distention is somewhat relieved, at the expense of 
toxemia, the blood escaping the detoxicating function of the liver cells. 
The spleen enlargement is partly due to a similar cirrhotic process. 
Ascites usually develops slowly, but may follow a blow or a cold quickly. 
The fluid is yellow, sp. gr. 1012 to 1014, and contains 0.6 to 1.2 per 
cent of albumen. It may contain a little blood and more albumen, 
especially if the serosa is inflamed. Edema of the lower limbs follows 
ascites. The urine is scanty from compression of the veins. The 
diaphragm is pressed up, and lung and heart-action impeded, the dyspnea 
becoming oppressive. Gastric ulcer may appear. 

The veins dilate and form collateral channels, the hemorrhoidal with 
the hypogastric, the inferior esophageal with the vena corona ventriculi 
and vena azygos, and veins in the hepatic ligaments and perihepatic tis- 
sue are formed and connect the liver and diaphragm. A vein in the 
ligamentum teres unites with those of the abdominal wall, the subcutan- 
eous vessels dilate and become visible, the skin edematous. But all these 
channels do not relieve the engorgement enough to remove ascites. The 
esophageal veins somestimes give way, and fatal hematemesis follows. 



580 CIRRHOSIS OF THE LIVER 

Hemorrhage or effusion may occur from any of the new-formed channels. 
The urine is scanty, high colored, heavy; the kidneys are compressed 
and arterial pressure lowered. Nephritis occasions albuminuria, vesical 
hyperemia, hematuria; urea lessens, ammonia increases, sugar is oc- 
casionally present; albumoses may be found, or leucin and tyrosin, sar- 
colactic acid and increased quantities of fatty acids. 

The heart is weakened by alcohol and by innutrition; the tempera- 
ture is subnormal as nutritional metabolism fails, though intercurrent 
acute exacerbations may raise it temporarily. Cachexia gradually super- 
venes; the patient, perhaps fat in the earlier stages, tends to emaciate 
later, the shrunken members contrasting with the tumid abdomen. 
Dropsy becomes general. In the later stages hemorrhages occur from 
depravity of the blood, not stasis, and may prove fatal. 

The same agencies that incite hepatic cirrhosis give rise to similar 
conditions in other organs; and we find the glandular cells of the stomach 
and duodenum replaced by connective tissue, interstitial nephritis, splen- 
itis, pancreatitis, and similar changes occur in the brain and meninges, 
the muscles, etc. Peritoneal tuberculosis develops with notable frequency. 

Prognosis: — No definite course; in adults it covers years. Change 
of habit may arrest the malady, and comparative health endure for years, 
with enfeebled digestion. Death is due to innutrition, heart failure, pul- 
monary edema, hemorrhage or some intercurrent malady. When de- 
cided atrophy is recognized the prognosis is bad; also when ascites has 
developed. General and increasing dropsy indicate the finish in sight. 

Diagnosis: — In the early stages the inferential, yet a knowledge of the 
causes of cirrhosis, with the presence of the typical digestive phenomena, 
point unerringly to the malady. If a man takes his whisky "straight" 
on an empty stomach several times a day and has done so for years, if 
he has morning nausea and gastric catarrh, ejecting glairy mucus, has 
little appetite and prefers raw and acid meats, with quantities of condi- 
ments, and suffers from hemorrhoids, it is not necessary to have a house 
fall on one to arouse him to a comprehension of the situation. Swelling 
of the spleen is then significant, and the liver may be palpated and be 
found firm or nodulated, somewhat tender. Examination of the ascitic 
fluid detects tuberculosis and carcinoma. 

Treatment: — Even in well-advanced cases a reform in the habits will 
arrest the malady — and if the patient still has enough liver cells to sup- 
ply his needs today they will supply them for an indefinite succession of 
tomorrows. Stop the alcohol; relieve the resulting depression by full 
doses of strychnine, contract the atonic and dilated viscera by berberine, 
one to five grains a day, relieve the catarrh by zinc oxide, gr.i and copper 



CIRRHOSIS OF THE LIVER 581 

arsenite, gr.1-100, before meals, and replace the condiments with hydro- 
chloric acid, pepsin, pancreatin, bile acids, papayotin or diastase, judicious- 
ly selected and dosed to meet the needs of each case. Above all keep 
the bowels clear and aseptic, with morning salines and sulphocarbolate 
of sodium, since the toxins of this tract contribute powerfully to aggra- 
vate the malady and add to its dangers. Arrange the diet to combat the 
anemia, debility and denutrition, giving freely raw meats, soused meats, 
raw eggs and oysters, fish, raw fruit juices, especially of the citrus family, 
and milk — if possible warm from the cow: Clam broth, turtle soup, but- 
termilk and similar articles are palatable to these patients. Small and 
frequent meals are the rule. Time must be allowed; chronic maladies 
do not subside acutely. 

Can we induce absorption of the new connective tissue? It has been 
claimed that the cirrhotic process can be reversed by ammonium chloride, 
nitrohydrochloric acid, salts of gold and platinum; and these claims have 
been derided but not disproved — or proved. Great benefit follows iheir 
administration, though we are unable to tell just why. Thiosinamin 
has been urged as a remedy capable of inducing absorption of cicatricial 
tissue, even to the reopening of old wounds; this seems the best estab- 
lished remedy, and may be given by the stomach in doses of a grain or 
or two, three times a day, for several months, with expectations of benefit. 
A favorite old Navy formula consists of ammonium chloride and strong, 
freshly-made nitrohydrochloric acid, of each four drams, water to three 
ounces; 30 drops in water before each meal, and the skin over the liver 
to be painted with the solution at the same time, until it becomes sore. 

With these remedies, judiciously applied — and patience — much more 
can be done in this malady than would be deemed possible by the tyro or 
the pathologist exclusively. 

Diarrhea relieves congestion — don't interfere unless it is unavoidable. 
Salines and sulphocarbolates relieve the useless part. 

Apocynin is the best diuretic: gr. 1-4 four times a day or more, " slows 
and steadies the cardiac action, increases blood-pressure, stimulates the 
kidneys and seems to have a tonic effect on the general capillary system" 
(Stengel). Tapping gives great relief and seems really curative in some 
cases, besides freeing the compressed organs from this obstruction; but 
removal of outside tension allows freer transudation of blood-serum, 
carrying with it albumen and other nutritive elements. When it has to 
be frequently repeated the writer has introduced Southey's tubes and 
drained the peritoneal cavity continuously, with benefit and impunity. 
Strict antiseptic precautions should be observed. 

The use of raw liver as a food is suggested. 



582 NEOPLASMS OF THE LIVER 

Hypertrophic cirrhosis Of the liver is rare, generally seen in men 
between 20 and 30 years of age, sometimes in the young. The causes 
are obscure. Alcoholism is disputed, and if active there must be some 
other unknown cause participating. 

The malady commences with indefinite digestive disturbance, anor- 
exia, morning vomiting, epigastric pressure, felt also in the right hypochon- 
drium; soon followed by jaundice, swelling and tenderness of the liver 
and aggravation of preceding symptoms. These and the jaundice sub- 
side leaving the liver enlarged. The attacks recur at long intervals, with 
increasing severity and duration, each leaving the liver larger. The 
jaundice becomes permanent, but not excessive. The stools are not achol- 
ic. The swelling of the liver causes visible protrusion. The liver is 
hard, the margin blunt and tender. The enlargement persists during 
life. The spleen swells also and is tender. There are no stasis, ascites, 
or collateral channels. The appetite returns and may be excessive, but 
nutrition fails and emaciation sets in. The urine changes with the con- 
dition, contains bile pigment and as improvement sets in becomes ex- 
cessive. 

Hemorrhagic diathesis develops. The course is slow, varied, the 
duration after permanent jaundice being 4 to 12 years. Hemorrhages 
become frequent near the end, with remitting fever and toxemia. When 
children are affected their development is impeded and the splenic en- 
largement is marked. 

The prognosis is bad, no cure having as yet been recorded. ( 

On general principles we should keep the bowels clear and aseptic, 
and until something better has developed adopt the treatment recom- 
mended for atrophic cirrhosis. The description of this malady given by 
Quincke points to a microbic infection by successive broods of some slow- 
ly incubating plasmodium. Sulphide saturation might be useful. Nu- 
clein or pilocarpine could be tried if the leucocytes were scarce, but no 
observations seem to have been made on this point. Otherwise the treat- 
ment is purely symptomatic. 

Cirrhotic affections of the liver occur in malaria, diabetes, and syphilis. 

NEOPLASMS OF THE LIVER 

Carcinoma, sarcoma and adenoma are rarely primary, commonly 
secondary to similar growths of the gall-bladder. Whatever be the cause, 
it must come from the intestine through the portal vein. Malaria, alcohol 
and traumatisms favor the development. Chronic irritation seems to be 
an important factor, and cancer often follows cholelithiasis. Melanosar- 



NEOPLASMS OF THE LIVER 583 

coma occurs rarely. Sarcoma is less frequent than carcinoma, usually 
secondary and then forms very large tumors. 

Symptoms: — They vary greatly, the general history being: Dis- 
turbed appetite, disgust for meat and fats; emaciation even with 
forced feeding; pallor, skin dry, fragile, wrinkled, sallow, perhaps slightly 
yellow; pressure and fullness in the liver; pain radiating to the abdomen, 
breast, right shoulder; liver enlarged, sensitive, nodular; decided jaundice; 
ascites; general dropsy; cancerous metastases in pleura, peritoneum, etc; 
death from cachexia and heart-failure. Sarcomas run a like but faster 
course. In adenomas ascites occurs earlier, the liver is harder, the course 
slower. The cachexia is probably due to the absorption of cancer toxins. 
Edema results from hydremia. The skin hangs loosely in folds; debility, 
dyspnea and palpitation increase, or irritability and insomnia occur 
apart from pain. Stupor and coma end the scene. The liver is enlarged 
in spots, sometimes universally. Unequally-sized nodules may be felt. 
Large sarcomas give a board-like hardness; small ones may be very 
soft. Symptoms may be added by pressure. Neuralgia of the right arm 
was noted by Mackenzie. If the outflow of bile is impeded the usual 
symptoms follow; if the portal is occluded evidences of its obstruction 
appear in the spleen and stomach, intestines and hemorrhoidal area. 
Various glands enlarge and secondary tumors appear. Fever is usually 
present to some degree. The red cells decrease. In melanosarcomas 
the urine is brown from melanin. 

Prognosis: — That of cancer — course slower in adenomas. Diagnosis 
begins with recognition of a tumor; the early cachexia, otherwise cause- 
less, resisting well-applied roborant treatment, progressive emaciation, 
slight continuous feveer, slight but persistent jaundice, all inexplicable 
and irremediable, speak for hepatic cancer when all other possibilities are 
excluded. 

Treatment is that of cancer. 

ECHINOCOCCUS CYSTS, ASCARIDES AND OTHER PARASITES 

Single and multiple echinococcus cysts develop in the liver, and in 
their course follow that of hepatic abscess, The diagnosis rests on the 
patient's residence in an infected district, association with dogs, the pres- 
ence of tenia in the stools, hepatic tumor with slight pain, tense and elas- 
tic, with a thrill, a smooth rounded surface, slow of growth and causing 
little disturbances, and the detection of the cyst elements on exploratory 
puncture. The treatment is surgical, but sulphide saturation might 
prove effective. 

Ascarides, flukes and other parasites occasionally invade the liver. 



584 FATTY LIVER 

FATTY LIVER 

The liver fat varies with the food. Normally from 3 per cent to 5 
per cent, it may be increased to 40 per cent. Fat may be stored in the 
cells or the protoplasm may degenerate, or both may occur together. 
Only degeneration causes symptoms. A deposit of fat may be due to 
a diet too rich in fats, with sedentary life, warmth and deficient oxida- 
tion. The tendency to fat formation is as yet unexplained. Fatty 
degeneration is caused by poisoning with phosphorus, arsenic, antimony, 
copper, mercury and aluminum. Mineral acids act less markedly. 
Carbon monoxide, petroleum, chloroform, iodoform, ethyl bromide, 
nitrous oxide, phenol, phloridzin, ricin, abrin, morphine, phallin, some 
proteid toxins and spoiled corn, cause varying degrees of fatty degen- 
eration. Chronic alcoholism, infectious maladies, chronic dysenteries 
and infantile gastroenterites, and phthisis, are destructive to the hepatic 
parenchyma. In phthisis the fat seems to be taken up from the rest 
of the body and deposited in the liver. The same thing occurs in many 
cases of cancer. 

The liver is uniformly enlarged, light in gravity, the margin rounded 
and soft, the fat increased and the water lessened, the tint yellow, the 
vascularity as seen at autopsy lessened. The acini contain fat globules, 
and show the cell protoplasm unaltered in simple infiltration, degen- 
erated in parenchymatous disease. Acute phosphorus poisoning shows 
only the former. In alcoholics the blood-serum contains much fat. 
Prolonged chloroform narcosis occasions cell necrosis. Many blood- 
poisons act on the protoplasm of the cells, while infections may cause 
inflammation. 

In the fatty liver of obesity the organ is soft, the margin indistinct, 
the dull area enlarged downward, not tender or painful, a sense of pres- 
sure or weight may be present, with no portal or biliary stasis if uncom- 
plicated. There are evidences of weak digestion — anorexia, flatulence, 
constipation, slimy stools, hemorrhoids and deficiency of bile. The 
general symptoms depend on the causal malady. The liver disease is 
a not especially important feature. 

The diagnosis is easy when the malady is advanced so as to occasion 
recognizable enlargement. The soft, indistinct margin, uniform, with 
few and slight evidences of ill-health, and the presence of the causal 
conditions usually suffice to clear up the case. The prognosis depends 
entirely on the cause. 

The treatment depends on the cause. Phthisis must be treated other- 
wise than by forced ingestion of fats. 



AMYLOID LIVER 585 

AMYLOID LIVER 

Amyloid degeneration never affects the liver alone, but the kidneys, 
spleen, etc., as well. It seems probable that hyaline change is a pre- 
cursor, and that amyloid substance is related to coagulated albumin. 
The most frequent precursor is suppuration of bone, including caries 
of bone and teeth, psoas abscess, necrosis, osteomyelitis and arthritis. 
We may also enumerate empyema, bronchiectasis, leg ulcers, hepatic 
abscess, pyelitis, gastric ulcer, dysentery; and in all these the presence 
of syphilis increases the disposition to amyloid change. Whether 
malaria, gout, rickets and mercury also increase the disposition has been 
claimed but not proved. Tuberculosis is the most frequent of all causes. 

The entire liver is enlarged, its surface smooth, contour unaltered, 
tissue firm, waxy and translucent if as usual it contains little blood; the 
acini indistinct, the changes most manifest in the intraacinous capillaries. 
The application of iodine changes the color to mahogany brown, of a 
layer of waxy material under the endothelium. The liver cells are 
atrophied, or fatty. 

Only decided degenerations can be recognized, and these require 
long periods of time. The liver is enlarged, the edges sharp and hard, 
smooth, neither painful nor tender, with no portal stasis as the vessels 
are not narrowed, but a little serum may exude into the peritoneum. 
The spleen shows similar hard enlargement. Casts, epithelium and 
enormous quantities of albumin are found in the urine, if, as is 
usual, the kidneys are involved. Diarrhea occurs with slimy stools. 
The original suppurative malady contributes its symptoms. The bile 
is gradually lessened, the stools becoming acholic, urea and uribilin 
decrease from the urine, which is light in color. 

The prognosis depends on the causal disease. It is now known that 
amyloid infiltrations can be absorbed. The diagnosis is made by the 
painless, hard, smooth enlargement, absence of portal stasis, pres- 
ence of suppuration, and the implication of the kidneys and other organs. 

The treatment, prophylactic and direct, depends on the causal 
malady. The suppuration must be stopped and syphilis and other 
cachexia cured. Beyond this the treatment is symptomatic. 

The liver iron is largely increased in pernicious anemia, and in that 
attending bothriocephalus; also in acute enteritis of children, typhoid 
and other acute fevers, phthisis, leukemia, diabetes, hyperemia of the 
liver, chronic diarrhea, atrophy, malaria, granular atrophy of the kidneys, 
artificial plethora, after large subcutaneous extravacations of blood, 
massive cellular hemorrhages and in hepatic cirrhosis. 



5 86 NEURALGIA OF THE LIVER 

In wasting of the tissues many red cells are destroyed and their iron 
stored in the liver. In any condition where red cells are lost this occurs. 
Why the liver cells alone take up iron, and in other cases only the capil- 
laries store it, is unknown. 

There are no specific symptoms beyond those of the primary malady. 
The existence of siderosis may be inferred but is not diagnosable during 
life. The treatment is that of the causal affection. When the anemia 
is due to absorption of intestinal ptomains the diet may be regulated, 
the bowels thoroughly evacuated and disinfected (Quincke). Since 
artificial siderosis recedes the pathologic form may be remedied by the 
free use of water and the vegetable acids and their salts, with natural 
fruit acids. 

PIGMENTED LIVER 

Normal pigment is found in the aged and in atrophy. Bile pig- 
ments at times stain the liver cells. Rusty iron pigment has just been 
discussed. Brown pigment is seen in venous congestion. Malarial 
pigment is stopped in the capillaries and connective tissue. Melanin 
forms black granules in the cells of sarcoma. These phenomena are 
part of the history of the affections named. 

Functional disturbances of the liver offer a field for the future clini- 
cian and pathologist. They may be assumed as following anomalies 
of digestion, disordered metabolism, infections and psychic disturbances. 
The symptoms of "biliousness" have little if any connection with this 
organ, but the intestinal decompositions on which they depend un- 
doubtedly influence it at the same time. The whole subject is as yet 
"in the air." 

NEURALGIA OF THE LIVER 

Violent spasmodic attacks of pain in the liver that can not be ana- 
tomically explained are set down as hepatalgias. The attacks resemble 
gallstone colic; last some days, in the worst forms. The patient is pros- 
trated, excited, restless, pallid and collapsed, pulse small and irregu- 
lar, rapid or slow. The pains may remain in the liver region or radiate. 
They may be increased by pressure over the liver, the gall-bladder, or 
other points. Vomiting is frequent, but never chills or fever. Jaundice 
is absent and the size of the liver is unaltered. The attacks may pre- 
cede or accompany menstruation, occur nightly or recur in weeks or 
months. The causes may be menstrual, social, dietetic, or psychic. 






DISEASES OF THE PORTAL VEIN 587 

Alcohol, spices, vinegar and tea have been blamed. The malady occurs 
in neurotics, anemics, especially in young girls. Other nervous phe- 
nomena are present or have been. 

The cause may be irritation of the hepatic plexus, spasm of the bile 
ducts, or generally the manifestation of "reflex" irritation at the point 
of lowest resistance, the excitant being anywhere in the body. The 
diagnosis is made by exclusion. The treatment depends on the true 
cause, and this may be somatic or psychic. 

DISEASES OF THE PORTAL VEIN 

By the portal vein are carried to the liver many noxious substances 
taken up from the bowel; hence the frequency of disease processes com- 
mencing in its terminal branches. The vein itself, however, is rarely 
diseased recognizably. Occlusion or narrowing may be caused by disease 
of the vein wall, compression from without, thrombosis, foreign bodies, 
and from unknown causes. Compression generally causes thrombosis. 
These pursue the usual course — become organized or disintegrate. 

The symptoms of portal obstruction by thrombi develop suddenly, 
perhaps on the symptoms of preexistent disease. Sudden epigastric 
pain occurs, followed by vomiting, diarrhea, and hemorrhage from 
stomach and bowels. The spleen swells and ascites rapidly develops. 
The hemorrhoidal veins are distended, edema of the legs follows swiftly 
and the cutaneous veins of the abdomen dilate. A venous network and 
edema may surround the umbilicus. The liver decreases in size but 
this can rarely be made out except just after tapping. Jaundice is pres- 
ent if the thrombus obstructs the bile passages. The bile is reduced 
in quantity. Secondary arterial thrombi may form, intestinal infarc- 
tions, or peritonitis develop. Sometimes these acute symptoms subside 
and reappear, the thrombus contracting and accretions being deposited 
later. In case of narrowing the symptoms may develop gradually, and 
the case is differentiated from cirrhosis only by the rapid ascites and 
gravity of the hemorrhages. Digestion is notably disturbed, appetite 
lost, absorption obstructed, with constipation, relieved by serous diar- 
rhea. The urine is scanty and may contain sugar. If only a branch 
of the portal is obstructed there may be no symptoms as the remainder 
of the liver carries on its function. 

The condition may end in death in a few days or drag along for years, 
depending on the occlusion of the whole vein or of a branch. The 
prognosis is not good unless the malady is syphilitic. When the causal 
malady is amenable to treatment there is more hope. 



588 DISEASES OF THE SPLEEN 

The treatment is that of the primary disease, and of the symptoms. 
Even in non-syphilitic cases a persistent course of mercury and other 
absorbents may cause the removal of some of the obstructing debris. 

PYLEPHLEBITIS 

The wall of the portal vein may undergo degenerative processes. 
Gall-stones and other foreign bodies, syphilis and tuberculosis, may 
cause irritation; leading to constriction and thrombosis. 

Acute inflammation may be caused by some foreign body, or exten- 
sion from intestinal ulcers or other suppurative foci, anywhere in the 
portal roots. The process is directly due to bacterial infection. The 
vein is occluded by the inflammatory products and embolism results. 
Secondary foci are formed which may be septic or not. 

The symptoms begin with thrombus formation. Septicemic fever 
and other manifestations are presented, and sometimes local evidences 
of the malady — pain in the cecum and spleen, swelling of the spleen, 
hyperemia of the liver and secondary abscesses. Jaundice is some- 
times present in varying degree; from pyemia, stasis or inflammation 
of the bile ducts. Local peritonitis may be present and develop into the 
general form. The disease usually runs too acute a course for stasis 
symptoms to appear, unless it is near to the end. The urine is scanty 
and may contain albumin or indoxyl. 

The course is uncertain as its beginning can not be fixed. The pri- 
mary attack may subside and pyemia develop in some weeks, enduring 
for weeks longer or months. The diagnosis is made by the symptoms 
of pyemia with hepatic abscess. Local symptoms are more common in 
chronic forms. The prognosis in unmistakable cases is hopeless, as a 
rule. If the primary focus is accessible and curable the inflammation 
may subside if not gangrenous. 

The treatment is that of the primary malady and usually surgical. 
The abortion of suppuration by the sulphides, reinforcement of leucocytes 
by nuclein, the toilet of the intestinal canal, and the careful support of 
the patient's strength, are indicated. 

X. DISEASES OF THE SPLEEN 

DISEASES OF THE SPLEEN 

Splenoptosis: — The spleen may be dislocated by descent of the 
stomach, by relaxation of its supports, or by increase in its weight. 



DISEASES OF THE SPLEEN 589 

Injuries may force it down, or the pressure of the corset displace it. 
Percussion and palpation detect the organ in its abnormal situation, 
even in the pelvis. It may be loose or adherent. The shape distin- 
guishes it from a fecal mass or a wandering kidney, as well as the 
absence of the dislocated organ from its normal situation. Pain is 
absent as a rule, unless the pedicle is twisted, when inflammatory symp- 
toms arise. The ureter, bladder or bowel may be compressed. If dis- 
tress arises a supportive bandage may give relief, or the organ may be 
attached to the abdominal parietes by stitches. 

Rupture of the Spleen: — This may be caused by violent injury or 
occur in the course of malarial or typhoid hyperemia, tumor or abscess. 
The symptoms are those of severe, peritoneal hemorrhage, collapse and 
local spreading inflammation. Treatment is surgical. 

Hyperemia of the Spleen: — An acute hyperemia occurs in malarial, 
typhoid and some other infections, suppressed menstruation, and 
beginning acute splenitis. The organ is engorged, soft, dark, the capsule 
tense. Chronic or passive congestion accompanies portal obstructions. 
Interstitial changes ensue in time. Hyperemia may cause a sense of 
fullness, tenderness or pain; the lower border may be palpated and the 
spleen is enlarged. The treatment is that of the causal malady, the 
bowels being at once freely acted upon, and the tension relieved by 
bleeding, pilocarpine, veratrine, or ice over the spleen. A small enema 
of cold saturated salt solution actively depletes the abdominal viscera. 
The intense vasomotor spasm of chills is soon relaxed by a full dose of 
atropine or of pilocarpine, hypodermically. The former is indicated 
when collapse threatens, the latter if the inflammatory symptoms approxi- 
mate the sthenic type. 

Acute Splenitis: — This may arise from injury, acute infections, 
embolism, or extension from other organs. The pain depends on the 
participation of the serous coat, which may also occasion friction recog- 
nizable by palpation and auscultation. The inflammation may be 
limited to the serous cover. The treatment is that of the cause, and of 
inflammation in general; depleting enemas and cathartics, vasomotor 
relaxants, local applications, etc. Sulphide saturation may prevent 
or abort suppuration. 

Chronic Splenitis: — Indurations form around infarctions, and follow 
congestions. Cases are supplied by malaria, syphilis, leukemia, pseu- 
doleukemia and typhoid fever. The spleen may be enormously enlarged. 
On section the surface is pigmented, the capsule hyperplastic, and the 
connective generally extended, the pulp cells increased in size and num- 
ber. In time the connective encroaches upon and replaces the cells, 



5QO DISEASES OF THE SPLEEN 

the induration increasing. The symptoms are caused by the increased 
weight and size — dragging and pressure, bowel obstruction, pain when 
lying on the right side; and the tumor, notched, with blunt borders, 
slightly movable with respiration, devoid of pain and tenderness. 
Dyspnea, palpitation and anemia attend. The treatment is that of the 
causal malady. Syphilis demands mercury biniodide, leukemia and 
malaria quinine arsenate and berberine. Polymnia uvedalia has reduced 
the enlargement when regular means failed, but probably depends on 
berberine for its activity. The latter may be given in doses rising to 
full toleration, for many weeks. 

Abscess of the Spleen: — Septic emboli from the heart sometimes lodge 
in the splenic vessels. Less frequently emboli come from other sources, 
or suppuration results from perforation by peptic ulcer, or from trauma. 
Swelling occurs, with pain, tenderness, and the constitutional evidences 
of suppuration. The abscess may be single or multiple, partial or 
general. It may discharge into any part of the gastrointestinal tract, 
the pleura or the peritoneum. Death may occur suddenly from rup- 
ture, hemorrhage or peritonitis. The tumor is lower than in empyema, 
and follows suppuration elsewhere. The history does not point to the 
thoracic organs. Aspiration confirms the diagnosis. Fecal masses 
are movable, with constipation, can not be palpated as readily, and 
are attended with digestive disorders, perhaps vomiting and tympanites. 
The treatment of splenic abscess is by preference surgical. Otherwise 
we may abort by sulphide saturation, with free catharsis and enemas 
of saturated salt solution or glycerin. 

Embolism may occur in ulcerative endocarditis, pyemia and other 
infections. Benign emboli cause hemorrhagic infarctions, or these may 
result from thrombosis. The symptoms are uncertain but there may 
be chills, fevers, and local evidences of inflammation suddenly developing. 

Amyloid change may accompany that degeneration in the liver and 
kidneys. The enlargement is smooth, hard, with rounded edges. This 
rarely follows chronic suppuration of bone (including dental caries), 
syphilis, tuberculosis and chronic enterocolitis. There are no symp- 
toms attributable to the spleen except its enlargement. Enormous 
quantities of albumin are discharged with the urine. There is no known 
treatment except removal of the causal suppuration, when the malady 
may subside. 

Atrophy of the spleen follows connective hyperplasia, mostly in syph- 
ilitic forms. The only symptom is contraction; of the organ. 

Tubercles, gummata, carcinomata ; and sarcomata developing in the 
spleen axe usually overshadowed by similar developments elsewhere. 



DISEASES OF THE PANCREAS 591 

Echinococci may be distinguished by the aspirator and the absence of 
chills, fever and leucocytosis. 

Aneurism of the splenic artery is very rare. Diagnosis depends on 
the recognition of pulsation and bruits; the existence of pressure symp- 
toms, and the location. The treatment is that of aneurism in general. 
Splenomegaly has been treated under the name of pseudoleukemia. 

XI. DISEASES OF THE PANCREAS 

DISEASES OF THE PANCREAS 

The pancreas is so situated that diagnosis of its diseases is extremely 
difficult; they are rarely amenable to treatment, and even the autopsy 
is usually unable to determine their true nature as the gland is generally 
destroyed 

Hemorrhage: — This may be caused by penetrating wounds or con- 
tusions over the pancreas, cancer, fat-necrosis, cysts, arteriosclerosis, 
aneurism or thrombosis of the pancreatic vessels, scurvy, purpura, per- 
nicious anemia or some acute infection, obstruction of the circulation from 
phosphorus poisoning, passive congestion from cardiac disease or portal 
obstruction, or by acute inflammation. It has been noted more fre- 
quently in men, after the 30th year. The organ is infiltrated with blood, 
disorganized, attacked by bacteria, and shows areas of necrosis. The 
neighboring parts may be involved. Cirrhosis may be found, and the 
ducts and acini are obstructed with blood cells. The entire gland may 
be destroyed or only the head or tail. Blood may be extravasated about 
the kidney 

The symptoms accredited to this accident are sudden, stabbing pain 
in the pancreas, persistent vomiting, dyspnea, great restlessness, and 
the signs of collapse — cold skin and extremities, cold sweat, weak thready 
pulse, sighing, pallor, aphonia, etc. The bowels are constipated. 
Tenderness may be elicited about the umbilicus and to its left. 
The temperature falls below normal. The mind is unaffected until terminal 
coma supervenes. Zenker attributes the sudden death that generally 
occurs to depression of the solar plexus. If death is postponed the 
temperature rises and tympanites obscures the dullness. Suppuration 
or gangrene may follow if the patient lives long enough. That recovery 
sometimes occurs is shown by evidences of an attack having been 
detected at post mortems. The diagnosis is surmised from the sudden 
and severe attack, and its location. Gastric or intestinal perforation is 
preceded by evidences of an ulcer, while the location and character of 



592 DISEASES OF THE PANCREAS 

the pain distinguish intestinal obstruction and gallstone colic. The 
treatment is surgical and palliative. 

Acute Hemorrhagic Pancreatitis:— Inflammation following hemor- 
rhage enlarges the gland, whose lobules are filled with blood and sur- 
rounded with areas of fat-necrosis. If time allows the cirrhotic process 
follows. The symptoms are those of hemorrhage followed by tender- 
ness and fever, local swelling, deep-seated induration, stiffness of the 
abdominal parietes and tympanites. 

Suppuration may cause single, multiple or general abscess of the 
gland, and perforation may occur into the stomach, duodenum, or peri- 
toneum. Pyelophlebitis and thrombosis sometimes ensue. The symp- 
toms are those of pancreatic inflammation with sepsis, chills or rigors, 
fever, sweating, delirium, and active leucocytosis. Jaundice or gly- 
cosuria may attend. The attack is attended with symptoms as above 
described, somewhat less acute. Treatment is surgical, the malady 
being too rare for observations on modern therapic methods to have 
been made. 

Gangrene sometimes follows hemorrhage, abscess, traumatisms or 
perforation by peptic ulcer. In two cases the gland was discharged 
by the rectum, the patients recovering (Chiari). It is needless to remark 
that such a result is scarcely to be hoped. 

Chronic Pancreatitis: — Catarrhal disease may extend from the duo- 
denum along the pancreatic ducts, causing connective hyperplasia with 
induration and atrophy of the glandular tissue. Calculi and pigment may 
be deposited. This may appear during diabetes, syphilis or alcoholism, 
or fat deposits may be present. The whole gland may enlarge or be 
atrophied. 

The hard gland may be taken for carcinoma. 

Cirrhosis may be general or partial. It is one of the curiosities of 
the post-mortem table. 

Pancreatic Fat-necrosis: — Flexner produced fat-necrosis by injecting 
pancreatic pulp into fatty tissue, and Williams likewise produced the 
affection in the skin. Tuttle found this affection attending interstitial 
fibrosis with artery disease. The gland cells may be atrophied, or the ne- 
crosis be limited to the interlobular and subperitoneal fat. The mesentery, 
omentum, epiploic appendices and abdominal fat may show similar 
necrotic areas. Hemorrhage may follow, or gangrene, sometimes ending 
in cysts. Diagnosis during life has not been made. The malady may 
not affect the health. 

Carcinoma: — Scirrhus and colloid may occur primarily; usually 
beginning in the head, and spreading to contiguous viscera or by the 



DISEASES OF THE PANCREAS 593 

lymphatics to the liver, etc. Or it may be secondary to gastric and 
other cancer. Pressure on the common gall-duct causes jaundice; nausea 
and vomiting are frequent, cachexia is marked and emaciation rapid. 
When the tumor becomes palpable pulsation may be imparted to it by 
the aorta. There may be fatty stools, glycosuria, salivation, or ascites. 
Paroxysmal pains are sometimes present. Aneurism is distinguished 
by its expansile pulsation and bruit; pyloric cancer by its movability, 
the presence of gastric dilatation and the abscence of jaundice; also of 
the characteristic pain some hours after meals. Cancer of the trans- 
verse colon is more movable, and causes intestinal obstruction. Pan- 
creatic sarcoma and syphilis have not yet been diagnosticated from car- 
cinoma. The treatment is surgical. 

Cysts: — These are rare, most cases having been found in adults. 
The causes are injuries, occlusion of ducts, and in some cases are 
untraceable. The pancreatic tissue may proliferate, the occluded duct 
enlarge, the cyst giving rise to hemorrhage into the lesser peritoneum 
or crowd the stomach up and the colon down, or the latter up also. 
Sometimes it lies above the stomach. Railton found a cyst arising from 
the tail, in the region of the left kidney. The cyst moves slightly with 
respiration. It may hold a few ounces or quarts. It may empty into 
the bowel and refill. Salivation, dyspnea and jaundice have been 
observed in some cases. Growth is slow with few symptoms until the 
size causes pressure effects. It presents a smooth, deep-seated tumor 
in the left hypochondrium or hpyogastrium, fluctuating if not too tense. 
Thompson found in one case intermittent tympanites from the entrance 
of intestinal gases. The stools may be acholic, rarely contain fat; gly- 
cosuria is common. The fluid removed by aspiration consists of pan- 
creatic juice. This completes the diagnosis, which may be inferred 
from the location of the tumor, emaciation and glycosuria. Treat- 
ment is surgical. 

Calculus: — The formation in the ducts resembles that of biliary cal- 
culi; from catarrh and probably infection. The calculi are single or 
multiple, white or gray, composed of calcium carbonate with some phos- 
phate; from a point to a walnut in size. They may cause cysts, atrophy 
or cirrhosis, ulcer, inflammation or suppuration. They may be the 
starting point of carcinoma. Attacks resembling biliary colic may occur, 
or there may be no appreciable symptoms. The pain and tenderness 
are deeply seated near the umbilicus; the stools may be fatty, or con- 
tain the calculi. If the main duct is closed emaciation follows. Gly- 
cosuria may attend. Diagnosis has not been established, or treatment 
preconized. 



594 ACUTE PERITONITIS 

XII. DISEASES OF THE PERITONEUM 

ACUTE PERITONITIS 

Peritonitis may be primary or secondary, partial or general, adhesive 
or serous. The surface of this membrane almost equals the skin in 
extent, and absorption from it is rapid. The membrane is injected, 
more or less glued together by lymph, the effusion being fibrinous, sero- 
fibrinous, purulent most frequently, or in cancer or tubercle hemor- 
rhagic. The coats of the bowels are edematous, their mucosa catar- 
rhal. The inflammatory process and products may be circumscribed 
by adhesions shutting them off from the general peritoneal cavity. In 
fact, the changes are closely similar to those described under the head 
of pleurisy. 

Etiology: — The causes are pyogenic bacteria, entering through per- 
forations; specific organisms such as the tubercle bacillus, streptococ- 
cus pyogenes, staphylococcus pyogenes aureus and albus, bacterium 
coli commune, pneumococcus bacillus of Friedlaender, b. pyocyaneus, 
typhosus, and proteus, gonococcus, aerogenes capsulatus, and anthrax 
bacillus, separately or variously combined; chemical irritants, mechani- 
cal, such as hernia; extension of infective processes; and very rarely it 
occurs primarily from exposure to cold and wet. 

Symptoms: — In perforations we have a sudden, sharp pain develop- 
ing at the point of injury, continuous, increasing in severity and spread- 
ing from the first point, increased by any movement and by pressure. 
Vomiting soon follows, often spontaneous, of greenish liquid with mucus. 
In markedly asthenic cases there may be little pain and no vomiting, 
but coma. Constipation is usual, eructations and hiccough are com- 
mon, or diarrhea may follow implication of the intestinal mucosa. The 
tongue is coated, becoming dry and brown with the fever. The heart 
is pushed up by effusion. The attack may be heralded also by a rigor, 
with intense shock, and fever develops rapidly, going to hyperpyretic 
points as the inflammation extends. The rectal temperature may be 
highest. The curve may present the peculiarties of suppurative fever. 
Respiration is rapid and shallow, the heart weak, the pulse rapid and 
small, growing more so toward the last. The face is contracted and 
pale, the lips and extremities cyanotic. The patient lies supine with 
legs drawn up. The urine is scanty and concentrated. Delirium and 
stupor are unusual. In the asthenic form the patient is overwhelmed, 
the temperature subnormal, the pulse excessively weak. The abdomen 
becomes distended as effusion is poured out, and the bowels may be 






ACUTE PERITONITIS 595 

palsied. If the abdominal mucles are stronger the effusion is less, and 
the abdomen is tense. The heart and diaphragm are pushed up. 
Tenderness is extreme, worst about the umbilicus. Friction sounds 
may be detected early. Tympany is exaggerated at first, the liver dull- 
ness less, fluid effusion causing dullness later, in dependent parts. 

Asthenic cases die within a week; the sthenic within two days. 
Death may be due to shock, or heart failure. The prognosis is better 
in primary cases, and in perforation if surgical intervention is prompt. 

In children peritonitis may be due to syphilis (congenital), to 
sepsis from the cord, to trauma or to appendicitis. The child utters only 
short cries suppressed by pain, digestive features are less prominent, 
tympanites marked, convulsions common and fever very high. 

Localized Peritonitis: — The inflammation is confined to a part of the 
serosa only, covering a single organ, as perihepatitis, perisplenitis or 
perinephritis. It may be due to cancer. (See Appendicitis.) Sub- 
phrenic pyopneumothorax is a peritoneal abscess containing air, between 
the liver and diaphragm. Perimetritis is the most common form, due 
to extension from the uterus, tubes or ovaries. Gonorrhea, puerperal 
sepsis and tubercle are causes. Abdominal or pelvic muscular rigidity 
attend it. 

The symptoms differ merely in their localization, the general condi- 
tions depending on the extent of the surface involved. Rigors and other 
septic symptoms depend on the quantitty and virulence of the material 
absorbed into the blood. Extension to the general cavity follows discharge 
of the circumscribed collection into it. 

Diagnosis depends on the evidences of local inflammation, constant 
and often sharp pain, excessive tenderness as compared with inflamma- 
tion, of the organ underneath, without disturbance of its functions unless 
it is also involved, and the evidences of septic absorption. Adynamic 
forms present most difficulty but may be recognized from a study of the 
history. Hysteric peritonitis shows tenderness exaggerated as compared 
with general symptoms, usually no fever, but other evidences of hysteria. 
Perforation occurring in typhoid fever should be easily recognized if 
the case has been closely watched. In intestinal inflammations there 
are less tenderness, less fever, colicky pains, not constant, and diarrhea. 
In colic there are flatulent distention, borborygmi and no fever or other 
peritoneal symptoms. In abdominal myalgia the pain is on motion 
only, superficial, and detectable by contracting the affected muscles with 
a faradic current. Pleuropneumonia may resemble peritonitis but there 
are earlier rapid respiration and high fever, with the physical signs, - 
Rupture of a tubal pregnancy in fact causes peritonitis and hemorrhage. 



596 ACUTE PERITONITIS 

Rupture of an aneurism or an embolism of the superior mesenteric artery 
causes hyperacute symptoms with quick collapse. 

The prognosis is better than in general forms. Recovery may be 
only partial, possibly leaving adhesions which may work further dis- 
tress and peril. 

TreBtmetlt: — Absolute rest and quiet should be enjoined. The 
diet should be of small quantities of the richest and most readily digested 
foods, giving every two hours two to four ouncees of cafe au lait, 
bovinine, sanguiferrin, fruit juice, or one of the predigested foods or 
a raw egg, white or yolk as may be preferred. Raw scraped beef or 
grated oysters may give the maximum of nutrition with minimum of 
bulk. In asthenic forms nutrition must be pushed. In others the 
brief duration of the attack may save us disturbing the stomach and 
inducing vomiting by unwise efforts to feed. In acute cases an abso- 
lutely empty bowel is best. 

Anders says it is now conceded that nothing is to be gained by 
surgical interventions in mild cases of gonococcal, colon bacillus or pneu- 
mococcal infections. In this inflammation at least the profession is 
united as to the value of promptly emptying the bowels by salines and 
thus stopping the absorption of toxins from the intestinal nursery. The 
engorged abdominal vessels are also depleted, absorption favored from 
the inflamed tract, the danger of adhesions decreased, and the absorption 
of nurtitive element furthered. The action is enhanced by the use of 
exosmotic enemas, half pints of saturated salt solution every four hours, 
the saline laxative being given between. In sthenic cases calomel may 
precede the latter, giving gr. 1-6 every half hour till six doses have been 
taken. Speedy saturation with calx sulphurata, gr. 1-6 every ' quarter 
hour, and by nuclein solution, gtt. 10 every hour, dropped on the tongue, 
is imperative. Only in perforative forms is morphine indicated and then 
peristalsis should be prevented by full hypodermic doses. 

The dosimetric and defervescent triads are indicated in sthenic and 
asthenic forms, to control the fever and regulate the pulse. It is use- 
less to seek to assuage the pain by opiates — narcotism will supervene 
with the agony unrelieved. Locally, heat and cold are the only remedies 
chosen — in appropriate cases. The hot should be very hot, the cold 
very cold, to secure benefit. 

Tympanites will scarcely be troublesome if the bowels are kept clear 
and drained, but if it does prove annoying a turpentine enema and a 
few granules of physostigmine will give relief. 

In perforation the abdomen should be opened as quickly as possible, 
cleansed and the opening closed. 



CHRONIC PERITONITIS. 597 

CHRONIC PERITONITIS 

General peritonitis may be adhesive, following acute local forms, 
proliferative, thickening without adhesion occurring with organic 
chrhoses; cancerous with bloody or chylous exudate; tuberculous, the 
most important form, with bloody effusion; hemorrhagic, a form described 
bv Virchow, and following frequent tapping. Local forms accompany 
disease of the various abdominal viscera, the spleen, liver and appendix, 
causing firm adhesions. 

Symptoms: — The general form develops insidiously, with digestive dis- 
turbances, usually constipation, diarrhea in tubercular forms, and 
sometimes symptoms due to pressure exerted by adhesive bands upon 
the portal vein, portions of intestine, etc. There may or may not be 
pain in the abdomen. Obscure abdominal discomforts may be present. 
General symptoms are likewise vague and indeterminate. Hectic results 
from sepsis, with wasting and debility, and nervous phenomena. The 
underlying malady may afford some symptoms. The abdomen may 
project where collections exist, fluctuation may be elicited over fluids, 
with dullness on percussion. Friction, fremitus and sounds may be 
detected. Local forms are frequently latent, colicky pains being the 
most common symptom when any are present. Examination may detect 
local collections of fluid. Strangulation may be caused by obstructing 
bands. 

There is a form of serous peritonitis occurring in girls at puberty 
that closely resembles latent tubercular forms. The latter usually pres- 
ent more fever and rapid emaciation. The history may clear up the 
mystery, or inoculations of guinea-pigs with the exudate demonstrate 
its nature. 

Mild forms may recover after a chronic course, resulting in extreme 
debility. Tubercular cases may recover spontaneously or after surgical 
intervention, especially if the fever is slight. 

TreBtmetlt: — Begin with regulation of the sanitary conditions, the 
diet being extremely nutritious, the digestion aided in all possible 
ways. Flatulence causing pain, is to be prevented by excluding gassy 
foods and keeping the alimentary canal in good order. Exosmotic 
enemas keep the lower bowel clear, salines and physostigmine prevent 
accumulations in the upper intestines. Suppuration is to be combated 
by calx sulphurata and nuclein, fever by the dosimetric and defervescent 
triads, the strength sustained by the tonic arsenates of strychnine, iron 
and quinine, and the absorption of effused material promoted and 
adhesions removed by the use of the potent absorbent combination so 



S9 8 ASCITES 

frequently advised in this work. Other indications are to be met as 
they arise. 

ASCITES 

The direct cause of accumulation of serum in the peritoneal sac is 
obstruction of the portal vein. The fluid is blood serum, straw colored, 
brown in cirrhosis, bile tinted in jaundice, or blood-stained, s. g. ioio 
to 1014, clear or opaline, usually alkaline. It contains albumin, more 
in peritonitis, leucocytes, red blood cells, fat, endothelium and choles- 
terin. In chylous ascites the fluid resembles milk and contains fat, 
lymphocytes and sugar. In ascites adiposus the fat originates from 
degerated epithelium and there is no sugar. In old cases the pressure 
causes atrophy of the abdominal viscera. 

Etiology: — The flow of blood from the portal vein may be hindered 
by pressure in the liver, as in cirrhosis; pressure outside the liver, as by 
various tumors; portal thrombosis; pressure on the inferior cava, the 
hepatic vein or the lymphatics; chronic obstructive pulmonary condi- 
tions, as emphysema; peritoneal neoplasms; portal atony from albumin 
drain and impaired nutrition, as in cachexias; chylous ascites from lym- 
phatic leaks or filariae, or from unknown causes; and adipose ascites 
may occur from fatty degeneration, as in cancer and tubercle. 

Symptoms: — When a quart or more has been effused the patient 
begins to complain of a sense of weight or fullness, progressive, followed 
by dragging in the loins, disturbed digestion, flatulence, constipation, 
with dyspnea as the diaphragm is pressed up. The latter is increased by 
exertion or by lying down. The heart is pushed up and may be irregu- 
lar. Syncope occurs frequently. , Pressure on the bladder irritates it 
and micturition is frequent, the urine scanty and albuminous. 

The dependent portion of the abdomen projects, this changing with 
change in posture; the skin is tense, smooth and shining; the umbilicus 
pouches out; superficial veins are prominent; the thorax appears small 
above and distended below, the xiphoid cartilage curled out; breathing 
is hurried and thoracic. Fluctuation may be elicited, and a wave sent 
across the abdomen by tapping against one side. Percussion dullness 
is manifest over the fluid. This changes with posture but the presence 
of distended bowel prevents an absolute hydrostatic line being demon- 
strable. 

Diagnosis: — It is made by the history and the signs. Fluctuation 
shows the presence of fluid, its movable nature shows it to be free in the 
abdominal cavity, and the aspirator reveals the nature of the fluid. The 
history shows previous bad health, disease of the liver, lungs or heart, 



ASCITES 599 

the swelling commences below and is alike on both sides, more apparent 
on standing. The prominence flattens on lying on the back, the umbili- 
cus protrudes, fluctuation is general, horizontally and vertically, there is 
no aortic pulsation, the uterus is movable and a pouch may project into 
the vagina, when standing the dull line is tolerably regular and concave, 
when lying on the back the flanks are dull with tympany in front, the 
dullness shifting with change in the patient's position, and the ascitic 
fluid is clear, with s. g. of or below 1014. In ovarian cyst we find a history 
of previous good health until the tumor develops, dysmenorrhea but no 
organic disease of liver, etc., asymmetric enlargement at first, the umbil- 
icus never bulges, fluctuation circumscribed, sometimes aortic pulsation, 
displaced uterus and the cyst may be outlined by vaginal examination, 
the upper line of dullness convex when standing, dullness in front 
when lying supine, not shifting on change of posture, and the fluid has 
a s. g. of 10 18 or more, is thick and turbid. Pancreatic and hepatic 
cysts arise from above, and may be distinguished by the aspirator. 
Peritonitic effusions have a history of acute inflammation or trauma, 
pain is marked, the abdomen is irregularly prominent, never flat, 
fluctuation may be limited, palpation detects uneven prominences, dull- 
ness may not change with posture,- and the fluid is heavy, viscid and 
its color variable. That the bladder has been tapped for ascites does 
not show that the diagnosis presents any difficulty but that there are 
very careless doctors. The malady generally depends on chronic, 
incurable diseases and the prognosis lies with them. 

TreBtment: — Let us premise with the statement that the object of 
treatment is not so much getting rid of a few pints of effused serum as 
it is prolonging the life and promoting the comfort of the patient. 
The original underlying disease should be treated, and the nutrition 
and blood crasis maintained sedulously. All dropsies demand the 
strict limitation of the ingestion of fluids, with richly albuminous diet, 
so that the nourishing elements of the blood may be concentrated in the 
smallest bulk, and the pressure in the vessels thereby diminished. So 
also we find that abstraction of the effused fluids removes counter- 
pressure and is followed by freer drain of blood serum into the abdominal 
cavity and consequent loss of blood albumin and fibrin. As Niemeyer 
acutely observed, we will do more by giving iron and other tonics and 
letting the dropsies alone than by exhausting our patient's strength in 
endeavoring to drain away the effused serum. Give iron phosphate gr. 
1-6, calcium lactophosphate gr. 1, and berberine gr. 1-6, together, every 
two hours while awake. Iron increases the richness of the blood, the 
lime increases the strength of the cell walls and hinders the escape of 



6oo PERITONEAL TUMORS 

serum, and berberine increases the tonicity of connective tissues and aids 
the others thus. Let this be the standing treatment, with such additions 
as the symptoms indicate from time to time. Keep the bowels clear and 
clean, best with exosmotic enemas of saturated salt solution. The dry 
diet may be made exceedingly strict as the patient realizes the comfort 
ensuing, but must not be pushed to denutrition. In our enthusiasm 
for reform we need not kill our patient. 

Why should we seek to remove the fluid at all? It may so disturb 
the heart and induce dyspnea that some relief is essential. Then we 
may secure this by tapping and abstracting a little — half to one pint — 
of the effusion, just enough to give, comfort. This does not drain away 
the strength as a full evacuation does. Or if the patient can bear 
depletion well we may employ the "vegetable trocar," apocynin, giving 
gr. 3-12 every two to four hours until free catharsis is established, guard- 
ing well our patient meanwhile from the water cooler. Then in some 
cases tapping has actually proved a cure, as Roberts has shown, in hepatic 
cirrhoses, so improving the abdominal circulation as to allow a modus 
vivendi of the conditions to be established, or the original causative 
malady having stopped short of the mortal point. In old cases where 
tapping has to be repeated at very frequent intervals the writer has 
obtained good results in the way of comfort from the insertion of 
Southey's tubes, for permanent or continuous drainage of the peritoneum. 
The tubes should drain by a long rubber pipe into a bucket of water to 
prevent the access of air. Masses of coagulated lymph form at the 
peritoneal opening and in a few weeks occlude the tubes, necessitating 
placing them in new situations; but this is the only evidence of irritation 
we have ever noted. As such patients usually live in a chair, the mechan- 
ical arrangements are not difficult. Perfect asepsis is to be maintained. 

PERITONEAL TUMORS 

Carcinoma occurs as scirrhus, encephaloid and colloid, the latter 
usually in the omentum. Primary forms are rare, cancer of the liver, 
stomach or pelvis preceding. There may be many little masses or a few 
larger ones, the colloid being the largest growths. They are more 
common in women, elderly. Early symptoms are obscure in primary 
cases, consisting of local pain and discomfort, and the constantly 
increasing cachexia. Some fever occurs, with wasting, debility, and 
anemia. The nodules may be detected by palpation if there is not too 
much ascites. This is often absent in colloids, which fill the cavity with 
large, soft, non-fluctuating masses. In secondary forms we have the 



PERITONEAL TUMORS 601 

original formation in the stomach, liver or pelvis, with the addition of 
abdominal pains and ascites. There may always be found some fever 
in cancer cases, due to the inflammation excited, the absorption of an 
internal toxin, or of septic matter due to the necrosis. For a part of 
every cancer consists of tissues whose circulation has been choked off 
by compression of the nutrient vessels. When the ascitic distention does 
not prevent, the irregular nodules of carcinoma may be detected by 
palpation. Tubercular growths occur earlier in life and do not cause 
such marked ascites as cancer. The inguinal glands are affected in cancer. 
Proliferative peritonitis is of alcoholic antecedents. Hydatids have a 
different history, the fremitus, slower growth, less pain and cachexia, 
and the hooklets may be detected in the fluid. Intestinal cancer causes 
intestinal obstruction, colic and bloody stools. Retroperitoneal sarcomas 
cause obstruction of the bowels, neuralgic pains and edema of the 
legs, from pressure. They are not movable like peritoneal tumors, which 
shift with respiration. Exploration completes diagnoses. 

Fibromas occur in little nodules, lipomas as fatty masses in or under 
the peritoneum. Mixed forms are found. They are rarely diagnosed, 
but may be removed if early detected. 



PART VII 

DISEASES OF THE GENITO 
URINARY SYSTEM 



I. DISEASES OF THE URETHRA 



GONORRHEA 



Acute Anterior Gonorrheal Urethritis is an acute purulent inflam- 
mation of the urethral mucosa resulting from infection by the gono- 
coccus with or without staphylococci or streptococci. When the latter 
bacteria alone are present the disease, though apparently severe, is 
non-specific and may be easily controlled by the local use of non-injuri- 
ous germicides. In the ordinary (and specific) case in from one to 
four days after intercourse there occurs an itching or tickling at the meatus 
and a reddish blush will be noted at the orifice. Some pouting will be 
also often present. Within thirty-six hours either an opaline mucus 
will cover the meatus or there will occur a discharge. The redness 
and swelling increase and sharp sticking pain is complained of. Smart- 
ing occurs on urination and there is a constant increase in the discharge. 
At the end of the third day the symptoms are marked and there often 
exists considerable lymphangitis. A tight foreskin may become edema- 
tous and phimosis result, or paraphimosis may complicate matters. The 
patient may have chordee at night and suffer bitterly from ardor urinae. 
There is, moreover, a desire to micturate frequently. The lymphatics 
from the frenum to the groin may be inflamed, swollen and painful. 
By this time the comparatively slight and glairy discharge has become 
plentiful and mucopurulent. It may, even, by the end of the first 
week, be streaked with blood. The stream of urine is thin, often 
twisted or forked, or it may be voided drop by drop or in intermittent 
gushes. In a virulent case of gonorrhea the entire urethra may be 
within the week affected to the bulb and the corpus spongiosum assume 
the aspect of a cord-like tube. The follicles become indurated and 
may be felt as hard pea-like nodules along the urethral floor. Adenitis, 
cowperitis (infection of Cowper's glands) and periurethral abscess may 



604 GONORRHEA 

complicate matters. Hemorrhages may occur after urinating or spon- 
taneously. In the average case however we find merely a moderate 
degree of inflammation, a plentiful discharge, painful erections (chor- 
dee), decided ardor urinae and a slight rise of temperature. In diag- 
nosing the physician must bear in mind that every case of gonorrhea 
varies in its severity and a profuse discharge with moderate ardor urinae 
and but little inflammation is not infrequent. He should also make 
it a point in any doubtful case to have the discharge examined for 
gonococci, as it is quite possible for a profuse purulent discharge to 
appear within twenty-four hours after instrumental infection, etc. 

The height of the acute stage' is usually reached about the twelfth 
or fourteenth day. At this period, even in mild cases there is a sense 
of discomfort at the bulb and the pendulous urethra is extremely sen- 
sitive. Walking becomes painful and the patient "straddles." Pain 
in the testes and groin may be present. It is now if ever that the 
patient begins to show facial signs of the disease. He suffers while 
urinating; he finds it distressing to walk and more uncomfortable to 
sit down. At night chordee makes sleep impossible and as a result the 
face assumes a worn, haggard look. The temperature now will range 
from ioo° to 102 F. The discharge is generally more profuse in the 
morning; this is due partly to retention of the discharge and partly to 
the fact that there is a decided exacerbation at night. However, 
patients who keep to their beds have decidedly less trouble and dis- 
charge. If there has been any reasonable treatment, about this time 
the whole train of symptoms improves: redness and swelling subside, 
the discharge, while copious, loses its purulent character and gradually 
becomes milky, then mucoid. Finally the amount diminishes until 
either none is discernible or the familiar "morning drop" alone remains. 

The usual length of an attack of simple anterior . urethritis is from 
three to five weeks; but under appropriate treatment, initiated early, 
the disease can be cured in from ten to twenty days. If, however, on 
presentation the disorder has existed for a week or ten days, the treat- 
ment will be prolonged. Relapses are not infrequent and usually occur 
just as the discharge seems to have ceased. This is due to an infection 
of the lacunae or deeper structures. Sometimes these recurrences are 
easily controlled but occasionally they are more rebellious to treatment 
than the initial attack. 

The Examination of Urine: — In every case of urethritis the urine 
should be examined. In the very early stage this is clear and small 
bodies of suety appearance or like small pieces of broken rice will be 
found. If these are not present threads will be. This condition lasts 



GONORRHEA 605 

but for a day or two and then the urine becomes more or less opaque. 
If the first few ounces of urine are passed into a clean glass and the rest 
into another vessel the first urine will be cloudy and the second speci- 
men clear. This is the "two glass method" and proves the infection 
to be limited to the anterior urethra. If the infection has reached the 
posterior urethra or bladder the two specimens will be clouded. It is 
at this very early stage (prior to penetration by the gonococci to the 
epithelial layer) that steps may be taken for aborting the attack. Late 
in the first week or early in the second the urine becomes loaded with 
pus and debris. If allowed to stand the pus will settle to the bottom 
of the vessel and a layer of yellowish or greenish material, over which 
a cloud-like mass of mucus shreds floats, will be apparent. As the case 
improves the pus lessens but the mucus increases. Then both lessen 
and epithelial cells present, showing that reparative processes are going 
on. Finally even these cease and, if no morning gluing of the meatus 
occurs, the case may be deemed cured. In the declining stages of an 
acute attack the "two glass method" is of no value and it is necessary 
to irrigate the anterior urethra and then have the patient pass urine 
into a clean vessel for examination. If this shows gonococci or gonor- 
rheal shreds the bladder or deep urethra are infected. It the washing 
from the anterior urethra reveals gonococci and the first urine does 
also, it means that the infection has spread to the bulb. The residue 
(which will have passed from the bladder through a flushed urethra) 
may show nothing pathologic or may be loaded with pus and epithelium. 
In the latter case it is quite evident that the bladder is involved. 

Diagnosis: — Balanitis, in cases where there is an abnormally tight 
prepuce, may resemble urethritis as the parts are inflamed and infil- 
trated and a discharge exists. An examination of the pus with a micro- 
scope will reveal gonococci if gonorrhea is present and, if the foreskin 
is retracted, the glans washed and the first inch of the urethra irrigated, 
no pus will be found further in the canal. In cases of "pin-hole meatus" 
it is best to do a meatotomy so as to be able to get into the urethra. In 
some few cases a chancre may exist just within the meatus and set up 
symptoms like gonorrhea. The microscope and urethral speculum 
will settle the point. The discharge is, in these cases, muco-purulent 
and scanty, and the lesion can usually be felt. These conditions 
excluded, the physician cannot fail to recognize urethritis. The spe- 
cific character of the disease must be proven by the microscope. 

The prognosis in any case of anterior urethritis is good, but if the 
symptoms of posterior involvement become marked the patient should 
be warned that the disease may prove tedious. It should always be 



606 GONORRHEA 

borne in mind that epididymitis, cystitis or gonorrheal arthritis may 
develop even under the best care. Alcoholic and neurotic patients are 
likely to prove refractory as are also persons of rheumatic, tubercular 
or strumous tendency. 

Tredtment: — Of necessity this varies according to the stage of the 
infection. Within the first twenty-four hours an attempt may be made 
to abort the process. The patient should urinate and the doctor should 
introduce into the urethra a soft rubber catheter and, shutting off the 
canal behind by pressure with finger and thumb, irrigate the proximal 
portion for some minutes with a i-iooo permanganate solution. Then 
the next inch may be so treated and finally a retrojection catheter may 
be inserted for a few inches and the process repeated. A 1-3000 solu- 
tion of silver nitrate may be employed with even better results. A soft 
bougie containing largin or icthargan may then be inserted and retained 
till the next urination or irrigation. This serves to distend the urethral 
walls and constantly apply medication. Of late these bougies are pre- 
pared with a soft cotton core which, also, is saturated with a gonococ- 
cide. This medicated "core" drains the urethra by capillary action 
and also serves as a dilator. In acute gonorrhea, after lavage as above, 
a few drops of a weak cocaine solution should be injected into the canal 
before the bougie is inserted. Take pains to maintain asepsis. 

The patient should receive a purge (small doses of calomel and 
podophyllin followed by a saline) and be placed on gr. 1-3 of 
calcium sulphide every hour for forty-eight hours. Helenin gr. 1-6 and 
boldine gr. 1-12 may be given with barley water every four hours. 
Aconitine gr. 1-134 may be added to each dose for fever. 

A much more painful process (though often a more positively cura- 
tive one) is the irrigation of the urethra with a warm saturated solution 
of boric acid after urination. A urethral speculum is inserted and with a 
cotton-wrapped probe or applicator the infected mucosa is swabbed with 
a solution of silver nitrate, gr. 15 to the ounce. Great care must be 
taken to prevent an excess of the solution from entering the urethra. 
In cases which respond satisfactorily there will be a considerable amount 
of inflammation and discharge, and the patient should remain in bed 
for two or three days. The purulent character of the secretion grad- 
ually ceases and a thin watery discharge (perhaps slightly streaked 
with blood) takes its place. In some cases it is necessary to use an 
astringent solution for a few days to bring the mucous membrane to 
a healthy condition. This, briefly, is the "abortive treatment" which 
has given good results when instituted early enough — that is, within 
the first forty-eight hours. 






GONORRHEA 607 

After the second day the gonococci have burrowed into the epithelial 
layer and it is not such an easy matter to reach and destroy them. 
Irrigations are effective to some extent (if long continued and skilfully 
used), but injections are as a rule positively harmful — unless used merely 
to cleanse the urethra. The main reliance must be placed upon sys- 
temic medication and the use of soluble bougies. 

Before instituting any treatment the physician should make himself 
thoroughly familiar with the parts affected. The existence of a tight 
prepuce may lead to phimosis, balanitis, etc., moreover there may be 
a mixed infection and unless the prepuce is withdrawn a chancre might 
exist on the glans unnoted. Warts, if they exist, must be promptly 
treated. The meatus should be studied and, if too small, a meatotomy 
done. The patient should be instructed that rest and cleanliness, 
together with the support of the organs, mean everything. 

A gonorrhea bag should be ordered and the patient warned to burn 
all dressings and on no account to allow his towels or articles to be 
utilized by others. After each dressing of the penis the hands must 
be well washed, preferably in a mild antiseptic solution. A weak phenol 
solution answers. The diet must be restricted, and alcohol, spices, 
coffee and tobacco interdicted. The use of barley water ad lib. as a 
beverage has helped markedly. The doctor should always see to it 
that his patient knows what to do and how to do it; much damage has 
been done by careless, ignorant handling of syringes, etc. 

If a syringe is to be used the patient should use it first before the 
physician; if bougies are to be inserted he should before leaving the 
office insert the first one himself. Finally he should be requested to 
repeat the entire technique. If this is insisted upon the results will 
usually be much more satisfactory. 

The ordinary case of acute urethritis, in the early stage, requires 
this treatment. The patient urinates and the physician then irrigates 
the anterior urethra with either a hot boric acid solution or a solution 
of ichthyol — dr. one to the pint of water. The latter has given the 
best result. The patient is provided with a soft-rubber-nozzled glass 
or vulcanite syringe and is instructed to wash out the urethra with 
either the boric acid or ichthyol solution morning, noon and night, after 
first soaking the penis in very hot boric acid solution for ten minutes. 
If he is given the bougie treatment he is instructed to insert, after the 
first washing of the day, a soluble drainage bougie containing largin, 
zinc sulphate, hydrastin and ichthyol. This bougie is left in situ and 
the core ejected when urine is passed. At this time another bougie is 
carefully inserted, and so on till finally, after the night irrigation and 



608 GONORRHEA 

soaking of the penis, the last bougie is inserted at bedtime. The method 
of using the syringe should be well understood by the patient. 

It should contain half an ounce, and be used as follows: The 
patient should sit on the edge of a chair or stand with feet apart. The 
syringe being filled (and the bladder emptied), the patient grasps the 
penis and, with thumb and finger of the left hand separates the lips of 
the meatus. With the right he inserts the nozzle of syringe, and then 
with thumb in ring the fingers of same hand make pressure around the 
nozzle while the fluid is being inserted. The left hand steadies and 
straightens the penis. It is a good plan for him to constrict the urethra 
with the left hand about two inches down while the first dram of fluid 
is injected. This may be retained by keeping the nozzle in place for 
a minute and then removing it. Another similar injection may be made 
to fill the penile urethra and finally, the syringe being recharged, the 
entire urethral canal is filled until the fluid spurts from around the 
nozzle at the meatus. 

The injections should be done carefully and syringe and glans should 
be first carefully wiped with clean cotton. Between treatments the 
patient should cover the glans with gauze or cotton and then insert the 
organ into the gonorrhea bag. All cotton and gauze used must be 
burned. As soon as the first acute inflammatory symptoms have sub- 
sided a 1-200 protargol or 1-4000 permanganate solution may replace 
the ichthyol or boric acid. These may be gradually increased in 
strength, though, as a rule, the proportions given will, if used together 
with the bougies, produce excellent results. 

If the posterior urethra should become infected the solutions should 
be carried by the surgeon well down into the bulbous portion with a 
small velvet-eye catheter. 

Under this treatment the gonococcus gradually becomes extinct 
and normal tissue repair follows. It may be necessary later to use 
astringent solutions; a 1 per cent solution of zinc sulphocarbolate and 
muriate of hydrastine being perhaps the most efficacious. 

Another favorite formula is: Hydrastine hydrochlorate gr. 8; zinc 
acetate gr. 8; glycerin dr. 4; water oz. 4 — 6. Mix. Inject several times 
daily. If no bougies are used, this solution may follow after the first 
week: Largin dr. 1 — 1 1-2, aquae bullientis oz. 8. M. This solution 
should be dispensed in amber glass bottles. 

Internal Treatment:— During the initial stages it is essential that 
the urine be rendered as bland and unirritating as possible. Arbutin 
gr. 1 may be given with gr. 2 of sodium or lithium benzoate, every four 
hours; and every three hours five to ten drops of santal oil (in capsule 



GONORRHEA 609 

form) may be exhibited. In the first stages calcium sulphide must be 
pushed rapidly for its systemic effect; gr. 1-3 being given every hour 
for the first twenty-four hours, then half the amount for the next two 
days. Gelseminine may be given in small repeated doses to relieve 
inflammation and pain and prevent chordee, and full doses of magne- 
sium sulphate will be required each morning before breakfast. It is 
well also to tone the system with small repeated doses of strychnine (or 
brucine), iron and quinine. Aloin may be added if constipation exist. 
In the declining stages cubebin, hydrastin and eupurpurin will, if given 
together in moderate dosage (gr. 1-6) each, markedly improve the 
urethral mucosa. Camphor monobromate gr. 1, with salicin gr. 1-3, 
may be given at 7, 8 and 10 p. m. if chordee is troublesome, or 
gelseminine gr. 1-250 added to each dose. 

Two somewhat new but extremely useful remedies in obstinate 
cases are echinacea and thuja occidentalis. Gr. 1-2 of the powdered 
extract of echinacea (or five minims of the sp. tr.) should be given with 
gtt. 3 of thuja (sp. tr.) three or four times a day. Under this medica- 
tion — especially if combined with tonics and eliminants — the discharge 
rapidly lessens and perhaps disappears altogether. 

POSTERIOR URETHRITIS 

Urethritis, gonorrheal especially, may involve the entire urethra and 
the symptoms not vary much from those attending a case of anterior 
urethritis. That pain in the perineum, testes and groins is experi- 
enced when the deep urethra is involved, is true, but this may occur 
when the triangular ligament is reached. Once the bulb is infected 
the entire membranous and prostatic portions of the canal are involved. 
The desire to micturate frequently and the intense burning pain which 
accompanies the act, mark the majority of these cases. A peculiar 
feature which often marks the involvement of the deeper urethra is the 
sudden cessation of discharge, together with an increased desire to 
make water. If the two-glass test is made both portions of urine will 
be found opaque and infected. Or, just when an attack of anterior 
urethritis is fading, the patient will complain of pain in the perineum, 
frequency of micturition and scalding or tenesmus. This means involve- 
ment of the prostatic urethra. In some cases beyond these symptoms 
nothing is noticeable, but in severe infections profuse hemorrhages 
may occur and the patient becomes bed-fast. Fever is absent, there 
are few if any signs of systemic infection, though a sharp rigor may 
precede or follow hematuria. This is nearly always post-micturitional. 
Either total retention or incontinence may mark this condition. Pain- 



610 GONORRHEA 

ful erections and ejections of bloody semen also may be noted; inflam- 
mation having spread to the caput gallinaginis. Chordee is not pres- 
ent unless an anterior urethritis also exists. Prostatic abscess, stricture, 
or spasm of the compressor urethrae muscle may demand surgical inter- 
ference. Albuminuria is often marked. Posterior urethritis may be 
a serious matter, or so little important that its existence may not even 
be suspected. 

The duration is also uncertain and depends entirely upon the gen- 
eral health of the patient and the virulence of the infection. The 
whole train of symptoms may subside within four weeks or they may 
persist in varying degrees of severity for months. The signs of improve- 
ment are less desire to make water; greater intervals between micturi- 
tion and less sense of perineal discomfort. Late in the disease it is 
often impossible to find the gonococcus in the discharge. 

Practically the same internal treatment is indicated. Helenin, 
eupurpurin and hydrastin are all of service, and nuclein has given excel- 
lent results. Sounds or bougies should not as a rule be used (this does 
not apply to soluble medicated bougies), and no irrigations or instilla- 
tions should be given till the anterior urethra has been flushed. 

Warm boric acid solutions may be used twice daily, the physician 
in every case superintending the operation. When tenesmus lessens, 
instillations of silver nitrate will be called for. The earlier they are 
used the better. Begin with a strength of i- 10,000 and gradually 
increase till 1-4000 or even less is reached. Go slowly and alternate if 
it seem desirable with irrigations of alum or potassium permanganate. 
Barosmin and arbutin with hydrastin and eupurpurin are internally 
of great value during the declining stage of posterior urethritis. In 
some very severe cases after irrigating the urethra with a warm boric 
acid solution it is well to pass a fine catheter well back and instil a few 
drops of a 1-500 solution of silver nitrate. The relief is sometimes 
almost magical. If this is the case the injection should be repeated 
next day, an even stronger solution being used. Great care must be 
exercised. There is obtainable a small rubber tipped syringe (post- 
urethral) which presents a multitude of fine perforations at the distal 
end; this serves excellently for these instillations. Hemorrhages will 
cease as a rule promptly and if much distress exist on urinating (which 
will seldom be the case if barley water, lithium benzoate and baros- 
min or arbutin are given) hot irrigations of hamamelis will prove 
remedial. In both acute and chronic forms of gonorrhea the writer 
has obtained good results from the daily application to the urethra of 
thymol iodide, suspended in a bland, neutral oil. 



GLEET 611 



GLEET 



Chronic Gonorrhea is perhaps the bete noir of the general practi- 
cian. The gleety discharge may vary from the well-known morning 
drop (or even a morning gluing of the lips of the meatus) to a profuse 
mucoid outpouring which gums and stains the linen. The patient may 
state that he had a gonorrhea ten or five years ago, which was cured or 
was never quite cured as the case may be. He may however deny gon- 
orrhea altogether, and sometimes the discharge will be found to be purely 
catarrhal and of non-specific origin. Prostatitis, vesiculitis, etc., may 
set up a gleet, and frequently there is a granulated area or eroded patch 
in the deep urethra which persists in weeping, being especially trouble- 
some after sexual excess or a drinking bout. 

However in many cases there is a localized inflammation of the urethra 
which is as distinctly gonorrheal as any other symptom of the infec- 
tion. The disease is, as has been pointed out, possessed of a ten- 
dency to hang on, and as many patients discharge themselves as soon 
as the pain and inflammation, together with the profuse discharges of 
the acute attack cease, it is not to be wondered at that the infection is 
perpetuated indefinitely. 

It is well to examine carefully every case of gleet. Prostate, sem- 
inal vesicles and every other portion of the genitalia should be gone over 
and abnormalities noted. The urethra may be healthy save for a patch 
in the anterior portion or there may be posterior urethritis with inflam- 
mation of the bulbous portion, or marked inflammation of the urethra 
at the penoscrotal junction. 

It is as a rule safe to say that the morning drop means affection 
of the pendulous urethra, the discharge flowing to the meatus during 
the hours passed in the recumbent position. The frequent passage of 
urine during the day prevents the discharge from becoming visible. 
However there may be a marked urethritis of the bulbous portion of 
the urethra, and little, if any, discharge appear. The crypts of Mor- 
gagni and glands of Littre when inflamed often give rise to a viscid dis- 
charge, as also do the follicles upon the urethral floor. If these are in- 
volved examination will prove, as a rule, the lacuna magna — situated 
just within the vestibule — to be engorged and infected. From this 
locality issues a sticky fluid which glues the lips of the meatus each 
morning. Irrigations and injections ad lib. will fail to stop this condi- 
tion, and the only remedial measure is to cleanse out the little pocket 
with a blunt pointed hypodermatic needle and some peroxide of hydro- 
gen, finally touching the walls of the lacuna with silver nitrate solution, 



612 GLEET 

five grains to the ounce. This should be applied with a fine probe. 
Some stubborn gleets have been stopped this way in less than two days. 
Cowper's glands occasionally, when involved, cause an intermittent 
discharge. 

Posterior urethritis proper may follow the acute attack and drag 
along unrecognized for year after year. The patient complains of no 
pain perhaps and there is slight if any discharge. At periods however 
the latter presents and continues for days or weeks, to disappear again 
without apparent reason. In other cases though pus exist, it may not 
make its way through the urethra to the meatus, being held back by 
the compressor urethrae muscle and carried away when the bladder is 
emptied. Rarely such cases become, from sexual or alcoholic excess, 
most acute in character and pursue the typical course of an initial acute 
urethritis. 

Sy/npfoms:— If the posterior urethra is affected there may be a 
frequent desire to urinate, with more or less pain at beginning or 
end. This may be the only symptom, but on the other hand quick, 
sharp pains are felt, the testes and groin are tender or the patient experi- 
ences neuralgic pains and there may be slight or severe spasm of the 
detrusor muscles. Pollutions may occur and if there be much hyper- 
emia of the ducts blood may be voided. Patients often complain of 
interference with the sexual function also — especially of a sharp pain 
at the moment of ejaculation. Pain over or about the pubes or in the 
testes and perineum is frequently present, indeed there is no limit to the 
variety of symptoms which may attend this condition. Naturally the 
small infected area in the pendulous urethra will cause little trouble but 
a general infection involving the prostatic urethra, prostate, seminal 
vesicles and ejaculatory ducts will cause not alone local symptoms but 
affect the patient's general health. In these more severe ■ cases consti- 
pation, indigestion and consequent anemia exist, with the result that 
the victim becomes neurasthenic and depressed. At stool the fecal mass 
presses upon the prostate and causes the mucus present to be expelled 
and the appearance of this leads the patient almost invariably to the 
conclusion that he suffers from spermatorrhea. Nine out of twelve of the 
younger and middle-aged sexual debility patients will be found to suffer 
from chronic posterior ur thritis with complications. Even when few 
of these abnormalities are distinctly in evidence it will be found that 
there is diminution of the sexual force — premature emissions, lack of 
sensation, etc. In many cases of acute anterior urethritis the improper 
use of strong astringent solutions causes the formation of a stricture. 
In the posterior form however the continuous inflammation in the con- 



GLEET 613 

nective tissues causes first desquamation and finally a change in the 
character of the epithelium, the normal cylindrical variety being replaced 
by the flat or pavement epithelium. Watery patches or polypi may form 
and after a time tissue of a distinctly cicatricial character may be found. 
Ulcers and erosions are not infrequent and in healing cause a growth of 
connective tissue which may materially alter the caliber of the canal. 
These strictures are most troublesome and difficult to cure. 

From the above description it will be easily understood that the dis- 
ease is one requiring patience and skill and frequently diversified treat- 
ment. By the use of the endoscope (or even the urethral speculum in 
a good light) a good idea may be obtained of the condition of the anterior 
urethra. The prostatic portion should not be invaded save by an ex- 
pert, as sufficient knowledge of conditions can be obtained by examination 
of the urine, digital exploration of the prostate through the rectal wall, 
and a careful review of the symptoms. In most cases the urethral mucosa 
will present either a reddish or purple tint, the discoloration being 
limited to one side or extending entirely around the canal for some dis- 
tance. The membrane is thickened and sometimes a glairy mucus 
or pus adheres to it. If the follicles are involved (follicular urethritis) 
little red spots will be observed, slightly raised and often oozing pus. 
The lacuna magna offers an easily observed example. In some cases 
the membranes appear granular or papillomatous areas may present. 
These patches are rarely found within the first two inches of the canal 
but may exist at intervals into the bulbous portion. Even the most 
gentle instrumentation will cause smart hemorrhage from these areas, 
which consist of round cell infiltrations, hypertrophied epithelium and 
newly formed capillaries. In the worst types the entire urethra will 
appear red and thickened and eroded areas, ulcers, infiltrated plaques 
or papillary growths may be scattered throughout its length. 

TreBtment: — In most cases the use of antiseptic astringent irrigations 
will be essential, and if there exist a simple catarrh of the anterior urethra 
with superficial involvement only this measure if persisted in may prove 
all sufficient. Many cases are psychological and the absence of the 
morning drop (after perhaps industrious stripping) would cause the 
patient to feel a sense of disappointment. These men require a course 
of tonics, mild astringent injections and some good advice. If pus is 
present or gonococci evident, the patient will have to be told that pro- 
longed treatment is called for. If he present evidences of gout, syphilis, 
tuberculosis, rheumatism or diabetes, the proper systemic treatment 
will have to be instituted. Faulty assimilation and elimination will have 
to be corrected and these measures alone will often prove half the battle. 



&H GLEET 

If the urine is turbid and contains mucous threads and gonococci, 
and the urethra presents an inflammatory and catarrhal aspect, a daily 
irrigation with a 1-500 solution of alum and zinc sulphocarbolate will 
prove effective. If pus is evident the anterior urethra should be first 
filled with a 1-4 solution of hydrogen peroxide, and this should be repeated 
till foaming ceases. With the penis syringe, a warm boric acid solution 
is now used to flush the canal, and finally the anterior and posterior 
urethra is irrigated copiously. If it is possible to give the irrigation twice 
daily it will prove better. After a week or two a 1-1000 permanganate 
solution may be used, and if any eroded or granular patches are now 
discoverable they may be carefully touched with a silver solution — from 
1-1000 to 1-200 according to tolerance. As the condition clears up a 
mild solution of hydrastis, with boroglyceride and water, may be used 
daily. In some very intractable but seemingly uncomplicated cases the 
use of thallin sulphate (15-20 per cent solution) has proved speedily cura- 
tive. This solution may be alternated with either permanganate or 
silver nitrate. Carbenzol dr. 1 to 2, to the pint of water, is also of un- 
doubted service. In all these instances at least two quarts of fluid should 
be used and the injection should be made with water as hot as is tolerable. 
Mercury bichloride, mercurol, icthargan and protargol, are used. 

If for any reason it is evident that the posterior urethra is not affect- 
ed the irrigations should be given through a retro jection catheter passed 
down to the penoscrotal junction. The passage at the same time of 
a perfectly sterile steel sound will often prove beneficial, but the sur- 
geon must be governed by conditions as to the use of this instrument. 
It may do more harm than good, and if the patient complain of pain 
after the passage it is best to stop the sound, at least pro tern. Great 
care must be taken to render the sound surgically clean, and it should 
be passed only after the urethra has been cleansed. The alternation of 
sound and irrigator will prove perhaps the best method of treatment 
for ordinary uncomplicated cases. In some the bulbous urethra remains 
affected long after the rest of the tract is cured. Then instillation of 
a solution of silver nitrate is essential. Either a Braun syringe or a 
small soft catheter and convenient glass barrel syringe of a dram or less 
capacity is used. The end is passed until the orifice is in the bulb 
and the operator feels the slight resistance of the triangular ligament. 
Here ten to twenty drops of a 1-200 or 1-250 solution of silver nitrate 
are ejected. This treatment is repeated every week, and after the 
second day the patient may use at home either injections of some mild 
astringent or a mixture of thymol iodide in petrolatum. The latter 
is especially serviceable in these cases. 









GLEET 615 

The operator will perhaps soon discover that it is not so much the 
material he uses for his solutions as the way in which he uses them. 
Some men will cure with alum and silver nitrate, while others will fail 
with half a score of fanciful formulae. Gentleness, cleanliness, thorough- 
ness and the ability to adapt the treatment to the condition, are what 
count. Patches, erosions and ulcers will occasionally require the pas- 
sage of the endoscope and the direct application of silver nitrate solution. 
The writer himself has had excellent results with the following method, 
in cases where the bulbous urethra seemed to be seriously affected. In 
the morning a thallin solution (25 per cent) is injected through a catheter, 
and either the same evening or next morning the patient again reports 
and a catheter (metal), perforated with numerous holes and properly 
curved, bearing at the proximal end a cup for ointment and armed with 
a plunger, is inserted loaded with silver nitrate ointment (five parts to 
75 of lanolin and simple cerate equal parts). A small quantity is ex- 
pressed, the sound turned slightly and withdrawn. A cupped sound 
may also be used. If the latter is gradually increased in size we get stim- 
ulation and dilation at the same time. Citrine ointment, one part to 
simple cerate (or ungt. resinae) eight to ten parts, will also give excellent 
results in some old, sluggish cases, especially when marked with hyper- 
trophy of the prostate. If pain is occasioned a little cocaine may be rub- 
bed up with the ointment, or, preferably, a solution of cocaine in glyc- 
erin and water to which enough adrenalin chloride has been added to 
make a 1-2000 solution, may be instilled into the deep urethra, and after 
fifteen minutes the above ointment may be used. 

This method combined with irrigation of the anterior urethra with 
thallin or permanganate solutions, will usually prove effective even in 
old and severe cases. If there is much thickening of the mucosa in 
whole or part a solution of glycerin and iodine may be used for a few days. 
As a rule the endoscope will have to be used and a 3 to 9 per cent solu- 
tion applied with an applicator. Lydston recommends strongly this: 1^ 
Iodoformi dr. 4; tr. benzoin, balsam Peru a a oz. 1. M. This is intro- 
duced through the endoscope after the urethra has been flushed with 
a hot iodized solution. This writer is one of the few who emphasize 
the absolute necessity for invading frequently the entire area of infec- 
tion; especially the deep urethra. Copious antiseptic irrigations with 
the short meatus nozzle, together with direct treatment of special areas 
with silver nitrate, iodine or other antiphlogistics and alteratives are, 
in his opinion, the main requisites for success. In early manifestations 
of posterior urethritis the soluble drainage bougie containing boric acid 
gr. 1-4, zinc sulphate gr. 1-8, and oil of eucalyptus gr. 1-6; the wick 



616 STRICTURE 

carbenzol i drop, will prove promptly remedial and, as it is easily inserted 
and requires no instrumentation, is generally useful. By the use of this 
device the urethra is dilated, drained and medicated, the melted portion 
of the bougie sinking into the deep urethra to be partly absorbed. 

Finally in cases which refuse to yield to any of these measures it is 
essential that a thorough examination of the entire urethra be made and 
the area affected treated directly. Shotgun methods must be avoided 
and the results which often follow a single well-placed application 
of silver or copper will prove astonishing. Silver nitrate may either 
be fused upon a probe or a strong solution (forty to eighty grains 
to the ounce) applied on a swab. A good form of applicator is a 
glass tube with wooden rod fitting snugly and prevented from passing 
through the tube by a ring at one extremity. If a little cotton bearing 
the solution is inserted first the rod will make it protrude and this can be 
touched to the ulcer or eroded spot with safety. 

STRICTURE 

A stricture may be congenital or acquired — the latter predominating 
largely. The causes are various: Trauma (unskilful instrumentation, 
etc.), chemic (caustic injections), and acute or chronic inflammatory 
conditions. There may be merely acute engorgement or a distinct 
thickening of the urethral wall due to infiltration and plastic tissue 
formation. The first condition may occur in any acute urethritis and 
be followed by the latter. We may also encounter a spasmodic variety. 
In the latter there is no permanent obstruction and the passage of bou- 
gies or catheters invariably accentuates the condition. Frequently in- 
strumentation is the direct cause of the contraction. The surgeon will 
often find the bulbous bougie firmly held at some portion of the urethra 
and this means that the hyperesthetic diseased area resents the presence 
of the foreign body.. 

Spasmodic stricture may be due to reflex irritation; the ingestion 
of such drugs as turpentine or cantharidin, cold, sexual excess, acid urine, 
the presence of a foreign body, alcoholism or mental strain. In ex- 
tremely nervous patients the mere attempt at catheterization may cause 
the entire canal to become contracted. In other cases an instrument 
introduced cannot be withdrawn without difficulty. Gout, rheumatism 
and other disorders of the uric acid type may cause urethral spasm. 
Congestion originating in prostatic or vesical diseases may occur sud- 
denly and set up spasmodic retention. Occasionally urethrismus (chronic 
spasmodic stricture) may cause trouble. Fistula, testicular disease or 
ischiorectal abscesses usually prove to be the irritative foci. The sur- 



ORGANIC STRICTURE 617 

geon with bougie or sound in hand may find it difficult sometimes to decide 
how much of the resistance he encounters is due to spasm and how 
much to organic stricture, but it is safe to consider that the contraction 
is spasmodic, whenever the patient has hitherto passed a full-sized 
uninterrupted stream of urine. Experience will soon enable the operator 
to tell by the feel whether his bougie has passed through the unyielding 
ring of an organic stricture or merely overcome a spasmodic contraction 
of the tissues. The main points in treating this condition are to remove 
all possible sources of irritation; to correct constitutional disorders and 
lessen nervous irritability. Eliminatives are generally required; and 
tonics, sedatives or nervines should be exhibited as the case may demand. 
Instrumentation should be avoided if the urethra proves especially sen- 
sitive, but warm baths or even irrigations (using the glass nozzle at the 
meatus only) will often be of service. A full dose of hyoscyamine will 
generally give relief, but occasionally morphine or codeine will be called 
for. The writer some time ago discovered that a warm solution of lobelin 
introduced into the urethra soon causes subsidence of spasm, and allows 
the passage of a sound or catheter which prior to that could not possibly 
be introduced. In some cases of organic Stricture congestion (especially 
of the deep urethra) is set up and upon the surgeon attempting to pass 
an instrument, spasm is added, the result being complete and obstinate 
occlusion of the canal. Anesthesia will be necessary in such cases, to- 
gether with the instillation (at the point of resistance) of a solution 
of suprarenal extract. Then by gradual pressure the stricture can be 
passed. In cases of urethrismus the removal of the cause of irritation 
will be followed by a speedy cure. The urine in all cases should be 
carefully watched and hyperacidity or alkalinity prevented. Arbutin, 
eupurpurin and scutellarin, will all prove of service in hyperesthetic 
conditions of the urethral mucosa, and with these remedies triticum 
repens may well be combined. The local application of thymol iodide 
in oil has alone cured these cases. 

ORGANIC STRICTURE 

The existence of a fibrous stricture having been discovered the exact 
location, size and consistency should be determined. The Otis bougie 
is perhaps the best instrument for this purpose. Begin with a 15 F. and 
gradually increase till the largest bougie which will pass the constric- 
tion is found. If the meatus is at all constricted, cut it. Not infre- 
quently this step alone will relieve vesical irritability. If the stricture 
is of the traumatic variety it is apt to be situated at the triangular liga- 



618 ORGANIC STRICTURE 

merit, as falls, kicks, biows, etc., would naturally affect this portion of 
the canal. As we have here to deal with cicatricial tissue the treatment 
is difficult and frequently perineal section will be called for. This variety 
may occur at any age. Thiosinamin, five grains daily for three months, 
is said to have caused the absorption of the cicatricial tissue. 

Congenital stricture is rare and is usually limited to the extreme an- 
terior portion of the canal. Gradual dilatation after a thorough meat- 
otomy usually suffices to remedy the condition. In doing this simple 
operation insert a curved bistoury and incise from within outward and 
posteriorly. Insert a pledget of cotton and at intervals a meatus-bougie 
(or urethral speculum) till healing occurs. 

Strictures of large caliber in the penile urethra may not even be 
detected, for a medium-sized sound can easily pass through them. They 
may serve to set up reflex contractions of the deep urethra, and the latter 
condition will not yield till the stricture is cured. Perhaps the most 
frequent site of stricture is just within the meatus, or at the fossa navi- 
cularis. The bulbo-membranous portion is perhaps next. The prostatic 
urethra is never involved. 

In acute urethritis chordee may cause such tension that the mem- 
brane may yield and a stricture result. 

There are several ways of treating urethral stricture. Gradual dila- 
tion, electrolysis, divulsion, or internal or external urethrotomy, may 
be selected according to the variety of stricture or the preference of the 
operator. Gradual dilatation is adapted to large-caliber strictures of 
the deep or soft permeable strictures of the penile urethra. This method 
will in the hands of an expert yield excellent results where the novice 
would resort to the urethrotome. The patient should be given a saline 
cathartic and kept on a low diet for forty-eight hours prior to the first 
dilatation. The patient should urinate, the meatus should be washed 
with a creolin solution and the urethra flushed. The patient should 
be placed in the supine position with the thighs flexed. The Otis bougie 
having been used and the exact location of the stricture discovered, a 
sterilized curved steel sound with point just large enough to enter the 
stricture should be passed. Phenolized olive oil or glycerin will prove 
the best lubricator. Dilate slowly, never using force enough to make the 
thumb nail white, and remember always to use the strength of the finger 
and thumb only, not that of the arm. It is well to increase the size of 
the sound not more than three F. at each sitting, which should be at inter- 
vals of three days. If reaction is very marked and the temperature rises 
two or more degrees, double the time. When the stricture will admit 
a 32 F. the patient should return once a week, and the full size sound 



ORGANIC STRICTURE 619 

may be passed. Occasionally the stricture is resilient or recurrent, and 
after a time the old conditions again prevail. In such cases absorption 
will not take place and cutting will be necessary. The Thompson or 
Van Buren sound is commonly used but Lydston has devised an instru- 
ment which is even more satisfactory. 

The main points to be observed are asepsis, avoidance of force, 
patience, and the use of not more than three sounds at a sitting. Coax 
the sound through always and let it remain two or three minutes before 
withdrawing. Too much haste or rough handling will set up prostatitis, 
cystitis and possibly urinary fever. The injection into the urethra of 
a solution of lobelin — gr. 1-67 in thirty minims of hot water — will often 
permit the passage of a sound which otherwise could not be possibly 
used. 

Continuous dilatation is rarely advisable. It may however be used 
in tight strictures where instrumentation is difficult. If a filiform bougie 
has been finally inserted through a tortuous or tight stricture it may be 
tied in place for twenty-four hours and then a larger bougie inserted. 
This may be continued till a No. 10 or 12 F. can be passed; at this 
stage gradual dilatation should be begun. In some cases a very small 
catheter may be used instead of a bougie, and the cystitis which so often 
follows the continuous presence of a bougie prevented by flushing it and 
the bladder with a warm boric acid solution. Divulsion may be per- 
formed with either a Gross, Gouley or Thompson divulsor, carefully 
observing asepsis. Then a large steel bougie should be passed and a 
catheter tied into the bladder for three days. 

It should be remembered that divulsion causes trauma, while dila- 
tation mechanically stretches and causes absorption of adventitious tissue, 
thus permanently increasing the caliber of the canal. The reaction which 
follows the use of the sound is essential, but if it is too great inflammation 
occurs and this aggravates the condition. The physician should never 
attempt to pass a sound (or catheter) into a strictured urethra until he 
has passed the instrument into his own bladder and has become familiar 
with the technique. The hemorrhage which often follows sounding is 
if moderate not injurious of itself, as it serves to decongest the parts; 
should it become excessive cold applied externally will suffice to check 
it. In some cases bleeding will follow urination after sounds have been 
passed. If in such cases the patient will insert the penis into a vessel 
of very warm water and urinate therein, bleeding will be avoided. Sex- 
ual intercourse should be avoided during the period of dilatation. 

Cystitis may follow the use of the sounds, and if it does the bladder 
should be promptly irrigated with a solution of H2 O2 (one to four), 



620 ORGANIC STRICTURE 

then with a warm boric acid solution, and finally four ounces of carbenzol 
dr. i to the quart of water, may be inserted and retained for ten minutes. 
Internally methylene blue should be alternated with arbutin and collin- 
sonin, and the urine kept mildly acid. Methylene blue gr. i may be ex- 
hibited with a little powdered nutmeg, and cubebin gr. 1-6 or cantharidin 
gr. 1-5000 may be added. Arbutin gr. 1, collinsonin gr. 1-3, will be use- 
ful alternants. Barley water may be given with either compound in 
half-pint draughts, and at least four doses should be taken in twelve 
hours. Some one of the preparations liberating formaldehyde will also 
prove useful. If the urine is alkaline ammonium benzoate will be called 
for in full doses gr. 4-6 t. i. d. 

Internal Urethrotomy:— The cutting of strictures has ceased to be 
as fashionable as it was and the average physician nowadays hesitates 
to use the knife. In deep strictures the Maisonneuve urethrotome is 
the favorite; for all others Otis' instrument. When it is decided to do 
an internal urethrotomy (and in nearly all annular and most resilient 
strictures this operation is essential), the patient is prepared and under 
strict asepsis the dilating urethrotome is passed. That point of the shaft 
at which the concealed blade will appear when being withdrawn should 
be about half an inch below the furthest limit of the stricture. The 
screw is turned until the dilating arms are stretching the stricture thor- 
oughly and then the blade is slowly but steadily withdrawn, cutting as 
it comes, and the stricture is severed. The incision should be on the 
roof of the canal always,- in the penile urethra. The dilating arms 
should now be separated until the desired dilatation has been secured, then 
they are brought together and carefully withdrawn. Otis' rule is that a 
penis three inches in circumference should admit a No. 30 F. sound, and with 
each 1-8-inch increase, one size larger. The Otis urethrotome spreads 
to 45 F. and as it is rare to find an organ exceeding 4^ inches (admi ting 
a 40 F.) it is never permissible to dilate to the full extent of the instru- 
ment. Indeed, it is not advisable to go beyond 33 F. as a rule. As soon 
as the urethrotome is withdrawn a large bulbous bougie should be inserted 
and unless the canal is clear the instrument must be reinserted. Irri- 
gation with boric acid or a mild mercury bichloride solution follows, 
and the patient is put to bed with either an icebag or cold water coil ap- 
plied. In using the non -dilating urethrotome the guide and staff are 
introduced, the latter held in the median line and the blade inserted and 
pushed down through the stricture. The after steps are the same as when 
the dilating operation is done. General anesthesia is not usually necessary, 
a weak cocaine solution (2 per cent in a 1 per cent solution of phenol) 
being satisfactory. The addition of adrenalin chloride solution has been 



RETENTION OF URINE 621 

recently recommended and it certainly aids in preventing hemorrhage. 
The electrolytic method of treating stricture is not to be recommended 
and many surgeons have condemned divulsion, though of late years it 
has again become somewhat popular in the east. Urethrectomy should be 
attempted only by a practised genitourinary surgeon. 

External urethrotomy may be done with or without a guide. There 
are two operations, Gouley's (with guide) Wheelhouse's (without). The 
former is by far the most desirable. As at least two assistants are neces- 
sary and the patient must be placed in bed with constant attention and 
irrigation of bladder, this operation should only be done in a hospital 
or where the services of a trained nurse can be secured. 

After Care and Complications: — In all operations for stricture it is es- 
sential that the urine be rendered as nearly neutral as possible. In internal 
urethrotomy cases for twenty-four hours prior to the operation barley 
water should be given in pint draughts every four hours, with arbutin, 
lithium benzoate or ammonium benzoate if urine is alkaline. Euca- 
lyptol in five-minim doses every three hours is also an excellent agent, 
and boric acid, salol, the formaldehyde liberating compounds, etc., may 
be utilized as occasion presents. The annoying chordee which often 
occurs may be prevented by the exhibition of gelseminine, hyoscyamine 
and camphor monobromate. The bromides are not as useful as gel- 
seminine, and hyoscyamine (alternated with perhaps gr. 1-2 camphor 
monobromate) hourly for three doses at night. Hemorrhage will some- 
times occur during the first night and can be controlled by the application 
of cold and a full dose of atropine, followed by ergotin gr. 1-6 every 
fifteen minutes for an hour. Dilatation must not be pushed too vigor- 
ously or urethral fever may set in. Should this threaten, full doses of 
salines with aconitine and calcium sulphide will control it. 

RETENTION OF URINE 

This complication may occur either as a post-operative symp- 
tom or be due to the closure of the urethra by stricture or reflex 
spasm. Quite frequently the strictured patient appeals to the surgeon 
for relief, presenting a bladder swollen enormously. Here is where 
care is requisite. If relief is not afforded there may be either a rupture 
of the bladder wall and speedy death, or the urethra itself posterior to 
the stricture may give way and extravasation take place. This means 
danger of the most pronounced kind. The most marked depression 
— typhoid in character — may follow or gangrene of the parts ensue. 
Sometimes an abscess forms and ruptures, leaving a fistulous tract. 
In ordinary retention the passage of a catheter is often the only step 



622 PROSTATIC NEURALGIA AND HYPERESTHESIA 

required, but in stricture cases (especially if there exist inflammatory 
conditions) the attempt to pass an instrument will result in failure. 

The first step is to reduce spasm; a full dose of hyoscyamine or atro- 
pine may be given, but the writer prefers lobelin pushed at ten-minute 
intervals to nausea. Ten minims of a strong solution may be instilled 
into the urethra also. Put the patient into a hot bath, or bathe the 
parts with hot water. If a hot enema of saline solution is given it will 
help matters. If the situation is urgent (and do not allow a patient's 
complaints alone to make you deem it such) aspirate the bladder and 
draw off six to twelve ounces. Often this will relieve the spasm so 
markedly that a small catheter can be passed. This should be retained 
and depletive or other necessary treatment continued. If the catheter 
cannot be passed a filiform bougie may often be insinuated into the 
bladder and the urine will trickle away beside it. It should be tied in 
and later a catheter passed. Aspiration may be done, if needful, several 
times, using a fine needle, provided the site of puncture is sealed with 
iodoform collodion; and is always preferable to instrumentation if the 
stricture is of very small caliber and inflammation is present. In ordi- 
nary stricture if sudden retention occur, the surgeon who is familiar 
with the urethral conditions may feel that the passage of an instrument is 
impossible and proceed to aspirate. This is a mistake; often retention 
will cause such dilatation of the posterior portion that an instrument 
which could not ordinarily be passed will slip through with comparative 
ease. Therefore, in non-inflammatory cases the effort to pass an instru- 
ment should be made first. The local use of lobelin often aids greatly. 

The writer has succeeded by introducing a small catheter, with sty- 
let, down to the stricture and then turning on a stream of hot water. 
Slowly the congestion is relieved and the instrument passes through. 
Or dilate the urethra with warm oil. In such cases it is well to pass a 
tunneled dilator and stretch the stricture. Operation — gradual dila- 
tation or urethrotomy — should be done later. 

II. DISEASES OF THE PROSTATE 

PROSTATIC NEURALGIA AND HYPERESTHESIA 

These conditions are by no means unusual, and are frequently 
the source of infinite worry to the physician and torture to his 
patient. The first disorder manifests itself by frequent and excruciat- 
ingly sharp pains in' the prostatic region, frequently radiating down the 
inside of the thighs, through the testicles and along the cord, and ovei 



PROSTATIC NEURALGIA AND HYPERESTHESIA 623 

the perineal and anal region. The cause is often obscure, but usually 
there exists either a uric acid diathesis, or some other abnormality of the 
sexual organs. Congestion may accompany the condition but is not 
always present; a hyperesthetic condition of the prostatic urethra may 
also complicate matters. In many cases an examination of the urine 
will reveal metabolic disturbances which are fully sufficient to account 
for the trouble. If examination fails to show any inflammatory changes 
or hypertrophy and if the sound fails to reveal a hyperesthetic area in 
the deep urethra, a brisk purgation followed by a course of salines, 
with calcium carbonate, colchicine and boldine, will often prove cura- 
tive. More pronouced benefit will follow if the intestinal tract is ren- 
dered therapeutically clean with the sulphocarbolates. 

For the pain, temporarily, gelseminine, camphor monobromate and 
sodium salicylate will be indicated. Some remarkable results have 
followed the use of ergotin, gelseminine and barosmin, with macrotin. 
With the exception of gelseminine the remedies named are given in full 
and increasing dosage, the former not exceeding gr. 1-134 t. i. d. Rhus 
tox and bryonin have also proved of benefit where the rheumatic ten- 
dency was marked. Hot sitz baths are helpful and if any inflammatory 
condition exists a glycerinated solution of adrenalin chloride may be 
instilled into the deep urethra night and morning. 

Injections or local treatment however are as a rule contraindicated. 
If there exist a marked hyperesthesia of the prostatic urethra the free 
exhibition of cypripedin and eupurpurin with hydrastin, and instillations 
of thymol iodide with petrolatum, will usually soon bring about 
a change for the better. The same treatment (with the addition of 
tonics) will apply when there is premature emission or partial impotence, 
with sexual unrest. In a few cases the prostatic urethra may be rendered 
less sensitive by the direct application of silver nitrate in solution cr 
in ointment form. 

That the condition may be due to causes far removed must not be 
forgotten. The dilatation of a constricted sphincter ani, the removal 
of hemorrhoids, the cure of an anal fissure or even the severance of a 
short frenum, may speedily cure prostatic neuralgia or hyperesthesia. 
The measures above described may — with variations to suit individual 
cases — be applied in those cases of prostatic hyperemia which are so 
prevalent and so hard to recognize. The man who complains of fre- 
quent emissions or too speedy ones; who has a loss of prostatic fluid at 
stool or a sense of fullness and tickling in the prostatic region, may on 
examination, present no pathologic features. Think of hyperemia then. 
Vesicular irritability with a desire to urinate is another symptom which 



624 PROSTATORRHEA 

often attracts the patient's attention. The use of very hot or co'd 
water applied through a rectal plug and return pipe often proves use- 
ful. This is especially indicated when the patient constantly feels as 
though an orgasm were about to take place. The sp. tr. of staphisagria 
two minims every three hours — with collinsonin and small doses of 
hyoscyamine — gives prompt relief. In all these cases constipation 
must be overcome and the mind turned from sexual matters. 

PROSTATORRHEA 

This condition may be due to hyperemia, acute or chronic, or 
catarrh. In the latter case there is usually a cystitis and inflamma- 
tory enlargement. The orifices of the prostatic ducts are relaxed dur- 
ing congestion of the gland, whether it be due to natural conditions or 
disease, hence when undue hyperemia exists there may be an escape 
of prostatic fluid on slight provocation. At stool, after micturition (caus- 
ing a milky sediment), or upon sexual excitation fluid may escape. 
The spermatorrhea victim usually suffers in this way and imagines that 
he is losing semen constantly. In this idea the quack with his lurid 
literature confirms him. As a matter of fact — unless the vesiculae semi- 
nales be over-distended — semen is rarely thus excreted. However it 
does happen occasionally that straining at stool may cause the escape 
of seminal fluid into the prostatic urethra, and if the sexual debility man 
can discover this he uses the fact as a means of proving the danger in 
which the patient exists. Not a few of these charlatans however make 
up a paste of flour and water, which they let sour; a drop of this mixed 
with urine will, under the microscope, provide thousands of active 
"spermatozoa," and serve to scare an extra hundred dollars out of the 
victim's pocket. The treatment already outlined is often sufficient here 
— with the addition perhaps of tonics. The arsenates of iron, quinine 
and strychnine, with hydrastin and eupurpurin, will prove efficient. 
Staphisagria is remarkably useful also. Mild mercurials and salines 
must be given as needed and cold sponging will be useful. 

Instrumentation is rarely needed but in some few cases the cold steel 
sound helps. Cleanliness, dilatation of the rectum and a restricted 
diet will do a good deal. Suggestion should be used also to the fullest 
extent. The patient must be made to realize that he is not losing a 
vital fluid and is not impotent. This done and a normal condition of 
the bowel with regulated circulation and thorough elimination once 
secured, the rest should be easy. Lecithin should not be forgotten in 
those cases which present marked -exhaustion or nervous debility. 



ACUTE PROSTATITIS 625 

Finally, in intractable chronic cases, astringent solutions may be 
used. The use of a properly prepared soluble bougie is also suggested. 
The most useful hydrastis astringent is perhaps boroglyceride dr. 1, car- 
benzol dr. 2, glycerine oz. 1, water oz. 6. M. Massage of the prostate 
through the rectal wall with the finger-tip gives good results, especially 
if a dram of euarol is first thrown into the rectal ampulla. One mas- 
sage per week is usually enough, but the doctor will regulate the seances 
by the benefit derived. Prior to and after massage give a hot irriga- 
tion of the rectum. The free exhibition of tonics — quinine, iron and 
ar.enic — with thuja and staphisagria will always give good results. 

The condition musi be differentiated from the hypertrophy which 
is so often met with in men after forty-five. This condition may arise 
from a long continued inflammation but in the end distinct fibrous 
changes occur which do not yield to any medicinal or mild local measures. 

ACUTE PROSTATITIS 

Of all the painful and depressing maladies affecting the genito- 
urinary organs this is probably the worst. Infection may occur from 
the urethra; traumatism may be the exciting cause; sexual excesses, 
instrumentation or even exposure may be responsible. In certain gen- 
eral systemic infections the prostate may suffer; thus, acute prostatitis 
may follow an attack of mumps. The condition has accompanied 
smallpox and scarlet fever. In most cases direct infection takes place. 
Deep injections, the passage of sounds, etc., are often to blame. The 
varieties of the disease are not of great clinical importance. Acute 
suppurative prostatitis may be diffuse or circumscribed. Miliary 
abscess may exist or periprostatic abscess; in the latter case the pros- 
tate itself may not be the seat of suppuration. Quite extensive destruc- 
tion of tissue may occur, in this form the pus being pocketed about the 
rectum and possibly finding exit in or at the bowel margin. In hyper- 
trophy the formation of an abscess is not uncommon and is probably 
due to passage of instruments. That death may follow prostatic sup- 
puration should be remembered, and the possibility of urinary or ano- 
rectal fistulae following spontaneous evacuation of an abscess should 
cause the physician to use the knife as soon as pus is located. Acute 
cystitis or Cowperitis may be mistaken for acute prostatitis but as a rule 
the former condition can be speedily eliminated by examination of the 
urine and palpation of the prostate itself. In Cowperitis the prostate 
is not enlarged and the affected gland presents a round swelling to the 
exploring finger. Both conditions may exist simultaneously. 



626 ACUTE PROSTATITIS 

The first symptoms of the disorder may be vesical irritation or urinary 
retention. Marked tenesmus with dysuria are not uncommon and 
there may be difficulty and distress in defecation. Rarely the first thing 
to attract attention is the inability to urinate. Far more frequently 
the patient feels a heavy pain in the perineum and complains of head- 
ache, malaise and alternate chill and flushing. Gradually the whole 
parts feel as though carrying a weight, and lancinating pains are con- 
stant. The call to urinate is frequent but often the act cannot be 
accomplished, or if it finally is, pus or even blood may be voided before 
or with the urine. The severity of the inflammation, the extent of tis- 
sue affected, and the involvement , or escape of the prostatic urethra, 
serve to govern the symptoms. 

Acute suppurative prostatitis may not be recognized till pus is dis- 
charged into the urethra, and this having occurred healing may steadily 
progress and a cure follow. However this may not be the case; the 
cavity may remain as a pus producing sac, and bacteria may traverse 
the sinus from the urethra and cause prolonged suppuration. Acute 
attacks of urethritis and cystitis may complicate matters. Acute pros- 
tatitis being suspected, the probability of abscess formation should be 
considered and a sharp watch kept for any sign of pus formation. If 
the abscess points towards the rectum it is easily recognized and a sen- 
sitive finger can often detect the condition quite early through the induration 
of the perineum. The preexistence of a urethritis will make diagnosis 
more difficult, though careful examination will generally enable the 
physician to make a diagnosis. The fact that in every case of urethral 
disease acute prostatitis (suppurative or simple inflammatory) is a pos- 
sible complication must not be lost sight of. Many cases are due to 
the bungling attempts of the individual afflicted with gonorrhea to treat 
himself 

Treatment: — Give a brisk purgative. Nothing proves so effective as 
gr. i of blue mass and soda, repeated hourly till five grains are taken at 
night, and next morning early a saline should be exhibited. The treatment 
may be repeated next night. Aconitine, veratrine or gelseminine 
should be given in small doses every two hours, the first-named being 
perhaps the most generally applicable. Hamamelin hydrastin and 
ergotin should also be given in full doses. The depleting suppository, 
(magnesium sulphate with glycerin) may be used per rectum, one being 
inserted night and morning — or carbenzol suppositories may be used. 
The idea is to deplete the parts. If free watery stools can be secured 
without setting up irritation we have done much toward putting an end 
to the condition. If after each stool a copious hot enema can be given 



ACUTE PROSTATITIS 627 

much benefit will follow. The cases which are able to go about will 
often require little further treatment unless pus formation is feared, when 
calcium sulphide should be pushed, gr. 1-6 being exhibited each hour. 
The diet should be light and productive of little waste. A hot sitz- 
bath may be ordered at night. 

The more severe cases will have to be put to bed and more pro- 
nounced measures taken. Gelseminine will often here prove better than 
aconitine, and ice may be used locally. The writer has found however 
that this does not give as good results as hot applications, hot enemas 
and baths. The urethra should not be invaded unless catheterization 
becomes absolutely necessary. Too frequent examinations per rectum 
even are not advisable. The progrees of the case may be gauged by 
the symptoms. Frequently a cantharidal blister to the perineum (shaved 
thoroughly first) will end the process; if this is objected to iodine may 
be painted over the same area or leeches applied. Anodynes if neces- 
sary should be given per os, codeine being perhaps the best drug we can 
select, though hyoscyamine is useful. Tonics should be given in nearly 
all cases, nuclein and brucine being perhaps the most desirable. Diuret- 
ics are not indicated especially, through the urine should be rendered 
bland and aseptic with arbutin or formin. Barley water is the safest 
beverage, together with a solution of magnesia sulphate flavored with 
lemon juice and sweetened. Both may be taken freely. 

Should retention of urine occur the smallest, softest catheter that 
can be passed should be used or aspiration may be preferable, espec ally 
is this the case where the urethra is known to be infected and retention 
appears to be due to temporary spasm or engorgement. Under this 
treatment the case is apt to improve in a week — or less time — and with 
care recovery takes place. Relapses are however frequent and reinfec- 
tion may occur if the patient fails to follow up treatment. 

If suppuration has commenced, or takes place despite treatment, 
echinacea and calcium sulphide must be given constantly, and nuclein 
should be pushed hypodermatically; gr. 1 echinacea, or ten drops of 
the specific tincture every two hours, and gr. 1-3 calcium sulphide, will 
suffice in most cases. After forty-eight hours the dose may be reduced 
one-half. The treatment otherwise will have to depend upon the general 
conditions; fever must be controlled if excessive (it is seldom pronounced 
if the above measures are taken); the bowels must be kept freely open 
and the urine rendered faintly acid. Conservatism is desirable to a 
certain point but the moment pus can be distinguished in a definite 
amount an incision must be made and drainage secured. The incision 
should be in the median line — along the raphe — of the perineum; this 



628 ACUTE CYSTITIS 

location should be chosen even when the cavity can be located per rectum. 
The incision should be free and if necessary to cut deep along the urethra 
the underlying tissues should be divided with forceps and a director car- 
ried into the abscess cavity. In rare cases (generally old neglected ones) 
the abscess points near the anus, then the incision can be made over 
the area where the covering is thinnest. 

Sometimes several separate abscesses exist. Each one should be 
opened; wherever possible the cavities should be irrigated first with per- 
oxide of hydrogen, then with aqua cinnamomi, or phenol solution. Gauze 
drainage should be provided in all extensive abscesses. The possibility 
of urinary infiltration must be considered but it rarely occurs if proper 
care is taken. If an abscess ruptures into the bowel or if it is evacuated 
per rectum great care is necessary to prevent infection and fistula. Irri- 
gation will have to be frequent and it is desirable to put the patient to 
bed and insert a good-sized tube wound with iodoform gauze to secure 
drainage. The sphincter should be thoroughly dilated. The use of 
poisonous antiseptics is to be avoided here. Peroxide of hydrogen, 
creolin solutions, iodine, carbenzol and boric acid are to be preferred. 
Colloidal silver (ung't Crede) may be rubbed into the perineum or ap- 
plied per rectum. Systemic antiseptics and reconstructants will be re- 
quired for weeks. Urinary fistulas may result as a consequence of the 
abscess rupturing into the urethra or through the perineum. 

In all cases the prolonged use of vesical irrigations will be called for. 
The patient should not be allowed to pass from under observation for 
months, otherwise chronic suppurative conditions are likely. 

III. DISEASES OF THE BLADDER 

ACUTE CYSTITIS 

Acute cystitis is an acute inflammation of the bladder mucosa. In- 
fection is nearly always to be suspected. The rheumatic, gouty, 
alcoholic or strumous individual is prone to contract cystitis — especially 
if exposed to cold and wet. Urethral disease and rectal affections may 
cause it; bacteria, constantly present, which are harmless under ordinary 
conditions may when resistance is lessened set up inflammatory processes. 
That gonorrhea — often unrecognized — is in the great majority of cases the 
primal cause of cystitis is unquestioned, and it is also a fact that a large 
percentage of cases are but extensions of infection from the deep urethra. 
The passage of unsterilized instruments may easily set up cystitis of 
virulent character without infecting the urethra proper; especially is this 



ACUTE CYSTITIS 629 

the case with catheters which retain bacteria in the eyelet. Injections 
may be forced into the bladder and by their irritative or caustic action 
set up cystitis. The gonococcus rarely invades the bladder, and even 
when a specific urethritis exists, coincident cystitis is due to invasion 
by streptococci or other bacteria. Abnormal conditions of the urine 
may cause destruction of the epithelium lining the bladder, thus per- 
mitting access to germs and offering conditions favorable to their propa- 
gation, but that the urine itself sets up the condition is to be doubted. 
Whatever the immediate cause it is safe to say that congestion first of 
all existed. This applies even when a healthy bladder is infected by a 
catheter; some abrasion with the consequent congestion being neces- 
sary for bacterial propagation. In this connection the trauma caused 
by the presence of a calculus is to be considered. The exhibition of 
highly irritant drugs — turpentine, cantharides, etc., may cause primary 
inflammation. Acute cystitis is quite likley to assume the chronic form 
(so called "catarrh of the bladder"). 

The symptoms of cystitis are easily recognized. There is constant 
desire to urinate, with tenesmus, marked tenderness upon pressure 
(perineal, rectal or vaginal), pain is experienced behind the pubes, down 
the inside of the thighs, in the sacral region, and sharp sticking pains 
may be experienced in the glans penis. The urine is alkaline, loaded 
with triple and amorphous phosphates, turbid, contains mucous shreds, 
pus and later blood. The sp. gr. ranges from 1005 to 1015. As a rule 
fever exists early, the temperature rising to 101-102 F. or higher. Reten- 
tion of urine may occur. 

Treatment: — Rest is essential. The bowel must be kept clean and 
empty with mild mercurials and salines. Aconitine or gelseminine must 
be pushed early, and here again gelseminine will be found to surpass 
aconitine. Hyoscyamine is usually given in alternation with one of the 
above, and its anodyne action frequently proves sufficient; but in some 
cases codeine will be called for. The benzoates in full-sized doses, with 
arbutin and hydrastin, will prove the best diuretics. The diet should 
be light. Hot baths and hot applications over the perineum and bladder 
are of service. The main point in the treatment is to maintain free 
elimination of a normally acid fluid. Under the above treatment the 
symptoms usually subside, and then cubebin, chimaphilin or eupurpurin 
may be given with a view to restoring normal tone to the affected mucosa. 
If pus is very abundant calcium sulphide will be indicated and in this 
case it must be pushed to saturation of the patient. In gonorrheal cases 
^his drug is especially valuable. The physician will occasionally meet 
with cases in which vesical pain is so intense that the ordinary exhibi- 



630 CHRONIC CYSTITIS 

tion of anodynes proves insufficient. Great relief will be afforded if 
after irrigation two or three ounces of a i per cent solution of cocaine 
be thrown into the bladder and retained as long as possible. In irri- 
gating and passing the catheter for retention the most scrupulous care 
musit be observed as to asepsis. 

Often a debilitated condition exists in these cases, and here the arsen- 
ates of iron, quinine and strychnine — with or without nuclein — will be 
indicated. 

CHRONIC CYSTITIS 

This condition may succeed' an acute cystitis, of any causation, 
the latter gradually assuming a chronic type, or it may commence so 
gradually as to be unrecognized until well established. The presence 
of some irritant (foreign body, calculus, etc.,) sacculation, with retention 
of urine, tumors of the bladder- wall or neighboring parts, exerting pres- 
sure — prostatic diseases or urinary abnormalities, any one or more of these 
combined may cause chronic cystitis. In rare cases a rectovesical fistula 
or sinus from pelvic abscess may cause infection of the bladder. Pus 
may pass through the normal bladder without affecting it, as is evident 
from the fact that pyelitis may exist without cystitis, but' if congestion 
of .the bladder mucosa takes place, bacteria cystitis results generally. 
Tubercle bacilli may invade the bladder and the b. coli commune is fre- 
quently found in cystitis. The usual classification is catarrhal and sup- 
purative, ammoniacal and acid. It is said that the tubercle bacilli and b. 
coli alone are present in the acid form. In the alkaline bacteria exist, 
which decompose the urine. Suppuration with acid urine is rare and 
never due to instrumental infection. 

The symptoms resemble those of the acute disease but are less pro- 
nounced. The bladder refuses to retain even a small, quantity of urine, 
and the patient constantly micturates and is as constantly in distress. 
The pain may be pelvic or sacral, or situated just behind the pubic bone, 
radiating therefrom — just prior to, during and immediately after the 
act of urination — down the interior of the thighs, through the scrotum 
and penis. The peculiar backache which attends some cases of cystitis 
is diagnostic. It is constant but varies in intensity, becoming more 
intense upon exertion, when the bladder contains much urine, and prior 
to defecation. Rest, and an empty bladder and bowel, will cause the 
pain to practically disappear for the time. The urine is usually highly 
ammoniacal, though it may be acid, becoming, however, alka ine on 
standing. It is also fetid. Mucopus, mucus shreds and sometimes bloo<J 
are present, together with trip'e and amorphous phosphates in large 



CHRONIC CYSTITIS 631 

amount. If calculi are present blood in the urine is frequent and the 
passage of concretions not uncommon. However one or more large 
calculi may be present without causing hematuria or any distinct symp- 
toms not usually present in cystitis. Instrumentation alone can detect 
their presence. An important constitutional symptom of chronic cystitis 
may be eczema; quite a large number of patients sooner or later present 
this and other diseases of the skin, which are of course due to imperfect 
renal elimination. This leads to the conclusion that chronic cystitis 
affects to a greater or less degree renal activity. The absorption of the 
products of urinary decomposition is also the cause of systemic toxemia — 
of which the so-called urinary fever is a type. The entire train of dis- 
orders due to renal inadequacy (even to uremia) may have their origin 
in cystitis. The generally accepted idea is that the cystitis is always 
secondary to renal disease, but investigation will prove that quite fre- 
quently the cystitis existed primarily. This is an important difference, 
as it becomes in all such cases necessary to relieve the bladder conditions 
before we can hope to secure normal renal activity, with the accompany- 
ing improvement of the constitutional symptoms. A cystitis due to renal 
disease of a systemic toxemia may be ameliorated without markedly 
improving the patient's health, but if we can cure a chronic cystitis causing 
renal disorder the jons et origo of the trouble is removed and recovery 
rapidly follows, the whole train of symptoms rapidly passing away. 

It might also be well to caution the young physician not to forget 
that the nervous irritability and general mental disturbance may be 
due to a very great extent to the constant pain and wakefulness more 
than to any direct effect of the malady itself. The man who has to arise 
and empty his bladder several times each night is not apt to feel extremely 
brilliant in the day time, especially if he suffers constant pain. This 
pain and sleeplessness become then a special source of concern to the 
physician. 

TreBtment: — The most careful attention to the general hygiene is 
necessary. The diet must be limited and bland. Milk indeed should 
form the staple article of food. The bowels and skin should be kept 
active by mild measures — baths, enemas, etc., and the bladder itself 
must be kept as nearly clean and germ-free as is possible. Antiseptic 
diuretics, demulcent drinks and the proper irrigations, frequently repeated 
under aseptic conditions, will work a great improvement in a few weeks 
even if they do not cure. 

The choice of medicines in each case will depend more or less upon 
the urinary conditions. In early cases where the urine is highly acid, 
alkaline diuretics will be beneficial. Calcium carbonate and potassium 



632 CHRONIC CYSTITIS 

acetate may be given in such cases, but the most useful of all the alka- 
liners will prove to be a combination of ammonium benzoate, arbutin 
and cubebin. The benzoate should be given in dosage sufficient to pro- 
duce speedy effect — gr. 2-5 every four hours. Every two hours arbutin 
gr. 1, cubebin gr. 1-6, should be exhibited with a glass of thin barley 
water. Or if it is preferred the benzoate may be taken with the latter. 
Guaiacol and its derivatives will give excellent results, and eucalyptol 
is without question one of the best of the antiseptics. Eucalyptol and 
salol may be given together after the acidity of the urine has been some- 
what overcome, alternated with either arbutin, asparagin, barosmin, 
chimaphilin or eupurpurin, and hydrastin alone or in various combina- 
tions. Calcium carbonate with lithium gives relief in these cases, and 
may well be exhibited in alternation with eucalyptol and salol, each 
remedy being exhibited for twenty-four hours. 

The urine being fairly normal in character and amount, those drugs 
which derange the stomach — eucalyptol, guaiacol, salol, etc. — may be 
discontinued, and asepsis maintained with some formaldehyde-liberating 
agent (formin compound), or methylene blue. Neither of these should 
be given until the urine is fairly free from mucus, or while intense acidity 
prevails. 

By far the greater number of cases however present alkalinity of 
urine, and many of them suffer from retention to a greater or less extent. 
This residual urine, decomposed and bacteria breeding, must be flushed 
out before it can do damage. Here in many cases lies the secret of cure. 
Internally these cases require formin compound and benzoic acid in small 
repeated doses. Strychnine and hydrastin will have to be given for their 
tonic influence — systemic and local. . 

Triticum repens with barosmin and eupurpurin may be given in alter- 
nation, or as the main remedial agents, once the urine clears up and 
remains clear for some time. Some one or other of the more potent 
antiseptics must be given throughout however, even if in small dosage. 
To allay pain and assure rest hyoscyamine, codeine and cannabin will 
have to be depended upon, though a thorough regulation of urinary and 
bladder conditions will do more than any anodynes. However, hyoscy- 
amine in small repeated dosage may be relied upon in the early stages 
of a case to give freedom from pain and sleep. 

The local treatment is after all the most important matter. Do not 
accept a case of chronic cystitis unless you can attend to it yourself or 
know that your orders will be carried out. At first the irrigations must 
be very carefully given. Creolin is also an admirable agent but causes 
burning when used early, or in very inflamed or ulcerated bladders if in 



TUBERCULOSIS OF THE BLADDER 633 

efficient strength. Later it is perhaps our best application. Carbenzol 
may be used from the first, the only objection to it is that it stains linen. 
One dram to the pint of water is the usual strength. After irrigation 
a little 1 per cent solution of cocaine may be thrown into the bladder 
and left there for some time. However this is inadvisable. The writer 
has found olive or linseed oil bearing a very small proportion of menthol 
give immediate relief. This may be thrown into the bladder after irri- 
gation and left there to pass with the urine. Glycerin is not advisable 
alone. The use of solutions of bicarbonate of soda will suggest itself to 
the physician who has to deal with extreme acidity of urine. Boric acid 
may be used but is not as effective in chronic cystitis as in the acute form. 

In some cases irrigation will seem to make matters worse. When 
this is the case use smaller quantities of another solution. However, 
the natural smarting which follows the intravesical use of many anti- 
septics must be considered. In tubercular cystitis nothing will prove 
more efficient than thymol iodide in petrolatum. Two drams carefully 
warmed may be thrown into an empty bladder. 

Distfnct gonorrheal cystitis will call for the silver salts — argyrol, 
argonin, largin, ichthargon or protargol. Largin and ichthargon have 
given the best results. Silver nitrate may be used with care. 

Cystitis in Women: — The same treatment applies. The urethra 
may be dilated and the bladder thoroughly flushed with the chosen solu- 
tion. In distinctly infective cases of rebellious type the bladder mucosa 
may be swabbed with silver nitrate solution through the endoscope, dr. 
1-2 to the ounce of water may be used. Any uterine displacement should 
be corrected and vaginitis if it exists promptly treated. Hysterical 
females may require dilation of anal sphincter and urethra, and a course 
of tonics. Cypripedin, scutellarin and quinine valerianate, with the 
" triple arsenates" — quinine, iron and strychnine — will prove efficacious. 
Cases which refuse to improve may be curetted with a blunt curet. 

TUBERCULOSIS OF THE BLADDER 

Where a tubercular taint is suspected and symptoms of cystitis present, 
have the urine examined for the tubercle bacilli. The centrifuge will 
often reveal the presence of the germ at quite an early stage. Unfor- 
tunately the general symptoms are so similar to an ordinary cystitis that 
it is sometimes impossible to diagnose correctly. The cystoscope will 
aid greatly. Emaciation of the patient and passage of purulent or a 
bloody urine with no history of other possible source of infection should 
cause suspicion. Prompt systemic treatment is called for, iodoform, 
helenin and calcium sulphide being most useful. The arsenates with 



634 PYELITIS-PYELONEPHRITIS 

nuclein must be pushed freely. Guaiacol internally and locally (in 
solution) will give decided results and euarol may be alternated (locally) 
with this drug with advantage. Guyon uses pure guaiacol by instilla- 
tion. This treatment has been .quite enthusiastically commended by 
competent clinicians. The possibility of extensive ulceration is always 
to be dreaded, and if the involvement is extensive cure is impossible. 
A limited area — revealed by the cystoscope — may be curetted. 

When uric acid concretions exist, calcium carbonate compound (cal- 
cium carb., lithium and colchicine) should be given; ten grains every 
four hours, with plenty of water. The diet should be restricted. 

PYELITIS-PYELONEPHRITIS 

The malady known as Pyelitis or inflammation of the renal pelvis 
may be due to the presence of a calculus; to nephritis, ureteritis (ascend- 
ing cystitis), the infectious diseases (most common cause), exposure to 
cold, cancer or tuberculosis. Certain irritating drugs may also set up 
the condition. Pyonephrosis or pyelonephritis are really more severe 
forms of pyelitis, the latter term expressing the same conditions when 
suppurative and the former an accummulation of pus due to blocking 
of the ureter. In simple catarrhal cases there is pain over the kidneys 
(often the affection is bilateral), and the urine excreted is acid, turbid 
and filled with mucus, mucopus and epithelial cells. The condition may 
become chronic. Quite frequently the origin of a pyelitis is lost, attention 
having been centered upon the original disease. Usually the patient 
complains of fever and chills, exacerbations of pain in the small of the 
back, and nausea which may end in vomiting. Chills are often followed 
by profuse perspiration which may have a distinct urinary odor. In 
some cases the quantity of urine is decreased markedly and reflex anuria 
is not uncommon. Palpation reveals nothing, the kidney rarely being 
enlarged unless pyonephrosis exists. 

In chronic cases the general health suffers but local symptoms are 
less pronounced and fever if present is intermittent. The urine may 
be increased in amount and on examination proves acid or neutral, con- 
taining albumin, pus, epithelium and hyaline casts; granular casts 
are extremely rare. In severe suppurative cases all these symptoms 
are accentuated, and if pyonephrosis exists a distinct tumor can be felt 
on palpation over the kidney. If the condition persists the whole kid- 
ney may be practically riddled with abscesses. The pelvis may rupture 
and set up perinephritic abscess, or the pus become inspissated and 
the kidney contract. In exceptional cases the kidney may become ad- 
herent to some other organ and rupture into it. One of the main diag- 



NEPHROPTOSIS 635 

nostic points in pyonephrosis is the tumor in the groin; another inter- 
mittent pyuria, the blocking of ureter being as a rule incomplete. In 
cystitis pyuria if present at all is constant. 

Quite frequently when the pyuria is marked the tumor becomes small 
or indistinguishable; when the urine is free from pus the tumor becomes 
evident. The presence of such a fluctuating tumor, with pyuria and 
septic symptoms, means pyonephrosis. 

Pyelonephritis, as already pointed out, is really a more severe form of 
pyelitis, the infection here extending into the uriniferous tubules and 
parenchyma of the kidneys, converting the gland into a huge pus sac 
or causing multiple abscesses. In either cases operative interference may 
be demanded. Aspiration may be done in pyonephrosis but nephrot- 
omy with free drainage is preferable. If one kidney alone is implicated 
operation should be done early as infection of the other kidney may occur. 

The treatment in pyelitis and pyelonephritis consists in the exhi- 
bition of urinary and systemic antiseptics and tonics. Elimination via 
the skin and bowel must be stimulated and the kidneys relieved of as 
much work as possible. Salines are essential and such drugs as are 
given should be exhibited with abundance of w r ater. Arbutin should be 
pushed up to 20 grains a day and maintained for months. The condi- 
tion responsible for the pyelitis will often greatly modify the treatment. 
Cystitis must receive attention; nephritis will require its specific 
medication and systemic infections receive due attention. Fortunately none 
of these diseases prevents us from using effective medicaments. The sys- 
tem may be kept free from waste by calomel and saline. Calcium sulphide 
may be pushed till saturation, and glandular activity maintained by boldine. 

The circulation should be rendered as nearly normal as possible; 
small repeated doses of cactin and strychnine serving us well as vital 
incitants and cardiac tonics. Nuclein is invariably of service, not alone 
in the local diseases but as a general reconstructant. The main thing 
then is to support the system; relieve the kidneys as much as possible, 
and aim to bring about as rapidly as possible destruction of bacteria 
and reparative processes. 

IV. DISEASE OF THE KIDNEYS 

NEPHROPTOSIS 

Movable or Floating Kidney. This is a condition usually due 
to a relaxation of the perinephritic tissues. The organ may be found 
in almost any portion of the abdominal cavity. The right side is most 



636 RENAL HYPEREMIA 

often affected and women suffer more frequently than men. Tight 
lacing must be looked upon as the main cause in many cases. Women 
who have frequent pregnancies and are debilitated are "very prone to 
movable kidney. 

Rarely pressure on the biliary passages may cause colic and jaundice. 
Other symptoms sometimes present are constipation, edema, palpita- 
tion, flatulence, dysmenorrhea, dysuria and abortion. Pregnancy 
brings relief. Dietl's crises are sudden and severe attacks of colic, chills, 
fever, vertigo, vomiting and collapse, at the menstrual epochs or periodic. 
Hydronephrosis follows if the attack is due to obstruction of the ureter 
by twisting, etc. The urine is thick, scanty, with uric acid or oxalates. 
Pyonephrosis and gangrene sometimes occur. 

Symptoms: — These are often vague. There is a sense of discomfort 
with a feeling of "tugging" or drawing in the loins and occasionally the 
gastric disturbance is quite serious. Constant nausea or expulsive vom- 
iting may be noted. . At times the pedicle becomes twisted or pressed 
upon and then attacks closely simulating renal colic develop. Hysteria 
is apt to be a symptom. The kidney may often be found; upon pressure 
a sick faint feeling is complained of, akin to that experienced when the 
testicle is compressed. In some stout or muscular patients however it 
is impossible to discover the traveling gland, but deep percussion over the 
kidney area upon one side will develop a lack of resistance. The discovery 
of a reniform tender tumor anywhere within the abdomen, together with 
the presence of the symptoms described and absence of cachexia, 
will serve as sufficient grounds for a diagnosis of movable kidney. 

Treatment: — In light cases a course of tonics (berberine, 1 to 5 grains 
a day for months contracts the relaxed connective) together with rest 
and nutritious food will serve to control the condition. Seek to increase 
abdominal fat. A broad abdominal binder with a pad sewed in to make 
snug pressure under the kidney may be worn. In old and pronounced 
cases nephrorrhaphy should be done. This operation is safe, and if well 
done effective. Watson says over 90 per cent are relieved by supporting 
corsets. 

RENAL HYPEREMIA 

There are two varieties of hyperemia (congestion) of the kidneys; 
active and passive. The former may be due to exposure, preg- 
nancy, the exhibition of certain drugs such as cantharides, turpentine, 
squill, potassium chlorate, phenol, eucalyptus, copaiba, etc., chill when 
heated, or to the presence of any of the acute fevers. Ether is also 
blamed. Occasionally the passage of a catheter may set up the condition. 



REXAL HYPEREMIA 637 

The symptoms are pain, slight fever, a sense of heat or fullness in the 
loins, with, in some cases, marked reduction in the amount of urine 
passed; the latter may contain blood, albumin, and a few hyaline casts. 
Edema is not present. 

Tredtment: — Salines, the hot pack or hot compresses over the kid- 
neys with small doses of aconitine or hyoscyamine prove useful. The 
use of pichi has been strongly recommended and may be given with a 
good preparation of triticum repens. Arbutin, 1 to 5 grains a day, is 
very effective. Milk or milk and barley-water should be given ad lib. 
and the patient kept in bed. Hot saline enemas are of marked benefit. 
A full dose of pilocarpine (gr. 1-6) gives prompt relief. 

PASSIVE HYPEREMIA 

This condition of the kidneys generally accompanies cardiac, 
hepatic or other chronic disease; it is frequently present in lung disor- 
ders when the circulation is impeded. Tumors which exert pressure 
upon the renal veins, collections of ascitic fluid or even the gravid uterus, 
may set up passive congestion. In rare instances thrombotic obstruction 
of the vena cava or large renal veins will cause intense congestion. 

The symptoms are not hard to recognize. The primary disease 
causing the stasis must always be considered, as cyanosis edema, and 
dyspnea could not possibly be due to renal hyperemia alone, and we 
generally find one or more of them present. As a rule the urine is dark, 
scanty and of high sp. gr., 1030 to 1040 being not at all unusual. Albumin 
in small quantity is present and sometimes a few hyaline casts and red 
blood cells are noticeable. Pain over the kidneys is apt to be complained 
of, the patient describing it as a pressing, burning or pricking; if there is 
any displacement of the organ the pain may be distant from the renal site. 

TreBfmetlt: — The most important thing is to relieve the primary con- 
dition. A course of blue mass and scda, or calomel with iridin or 
boldine, will if followed by salines give prompt relief. The small divided 
dose is here particularly useful: gr. 1 of blue mass and soda, or gr. 1-6 
of calomel with an equal quantity of iridin and boldine, being exhibited 
hourly for four to six doses; three hours after the last dose a saline is 
given, and then even* three hours scillitin, digitalin, or possibly minute 
doses of gelseminine may be given, with arbutin or chimaphilin. The 
latter is particularly valuable and if alternated with the infusion of 
juniper may be regarded as one of the most promptly acting remedies. 
Of late adrenalin has been recommended. High enemas are indicated: 
three pints to two quarts of normal saline solution being thrown well 
up into the bowel and retained as long as may be. 



6 3 S UREMIA 

UREMIA 

This dangerous condition is often the first sign recognized of nephritis, 
patients who have been treated for various vague disorders suddenly 
presenting unmistakable signs of profound toxemia. Even with our 
present understanding of the body chemistry we are not able to state 
positively the nature of the toxins which produce the symptoms found 
in uremia, but there is no question that non-activity of the kidneys causes 
their presence in the blood. An examination of the urine will reveal 
decreased urea — possibly a total absence — and the specific gravity will 
be high; possibly a large amount of albumin and hyaline, blood and 
epithelial casts will be found; indeed the urine of the uremic patient will 
usually present all the pathologic features of nephritis. The pro- 
found coma and convulsions which occasionally come on abruptly are 
supposedly due to edema of the brain, but a better understanding of the 
metabolic processes will probably reveal the presence of a virulent toxin 
produced only under certain waste-laden conditions of the blood. 

Elimination, prompt and thorough in character, alone serves to save 
patients so affected. Uremia is apt to develop in any form of nephritis, 
and should be carefully guarded against. Headache, giddiness, asthma, 
hiccoughing, nausea or vomiting, dyspnea and a dry skin, with slow 
pulse of high tension, must be looked upon with suspicion. In some 
cases some one or several of these minor symptoms will attract the pa- 
tient's and doctor's attention, and if in addition there is scanty or almost 
total suppression of urine with uriniferous odor of the breath, it is cer- 
tain that uremic poisoning is present. Sudden mania, convulsions, 
coma, deafness or blindness, or partial paralysis, maybe the first thing to 
demand medical attention, and it is then necessary by examination of 
the urine and the past history, to recognize uremia. Uremic coma is 
invariably accompanied by a urinous odor of the bieath, the pupils are 
contracted evenly, temperature may be either above or below the normal 
but is usually 103 F., the aortic second sound is accentuated, and the 
urine (which has been scanty) invariably contains albumin. Urea is 
scanty or absent. The face is pale, often cyanotic, sometimes edematous 
and not infrequently a general dropsical condition of the body reveals 
the nephritic origin of the stupor. There is no history of epilepsy or 
other probable cause for coma. The patient may have complained 
of headache and delirium may have preceded unconsciousness. Cir- 
rhotic coma will usually be accompanied by jaundice, the patient will 
be emaciated, and epistaxis, hematemesis or bloody stools will have 
been noted. Traumatic coma can hardly be mistaken, and apoplexy 



UREMIA 639 

presents an entirely different picture, delirium or convulsions being 
absent and the urine presenting no deviation from normal. In apoplexy 
the tongue deviates and paralysis is evident. The malady may develop 
in chronic form. The convulsions may simulate petit mat, or grand 
mal. 

Treatment: — In the more serious forms of uremia elimination must 
be secured promptly, life depending upon the rapidity with which we 
work. The urine should be promptly drawn with a clean catheter and 
the bladder washed out with warm boric acid solution, a small quantity 
being left in the viscus. A plentiful and warm high enema of normal 
saline solution will be given, and after this has been rejected two quarts 
more will be thrown into the colon and retained by pressure upon the 
anus. A wet-pack should be prepared and into this the patient should 
be placed. Pilocarpine is given hypodermatically in full dosage, and 
elaterin pushed in frequent fractional doses; menthol should be added 
and hyoscyamine, gr. 1-250. Strophanthin, sparteine, scillitin or digi- 
talin will prove useful if vascular tension is low, and the selected drug 
may be given at frequent intervals to effect. If arterial tension is high 
a few doses of glonoin, gr. 1-250, will be speedily helpful but veratrine 
should be pushed rapidly to full effect. Salines may be given at hourly 
intervals. The patient should receive these medicines in the pack, being 
kept therein for at least two hours; by this time the bowel and kidneys 
will usually be acting freely and profuse perspiration will be produced. 
If unconsciousness persists dry cups may be applied or venesection prac- 
ticed. In extreme cases it is well to open a vein and allow twelve to 
eighteen ounces of blood to escape, and then inject into the opened vein 
(median basilic) double that amount of sterile normal saline solution. 
If however the bladder and bowel are speedily washed out and the hot 
wet pack used, the medication suggested will suffice in nearly every 
case. Very effective is a small enema of saturated salt solution. 
The exosmosis into the bowel from the blood removes the lethal toxin 
surplus. The doctor or nurse should remain with the patient till 
safety is assured. 

To prepare the wet pack: Cover a couch or cot with a quilt or rubber 
sheet. On this lay a thick dry blanket; wring a thick sheet or blanket 
out of hot water and carry it rolled to the couch; spread it and have the 
patient, perfectly nude, promptly placed in it and wrap him from toes 
to chin in its folds; over this wrap the dry blanket and then the quilt. 
Give medicines with a few swallows of saline solution and bathe the 
face with cool water, keeping a wet piece of linen on the head. When 
consciousness returns give veratrine or sparteine, according to tension. 



640 ALBUMINURIA 

A saline draught each morning will be needed also. Other treatment 
will be instituted as symptoms may demand. 

ALBUMINURIA 

Even in the healthy individual minute quantities of albumin, serum 
and sugar may be present in the urine, but it requires delicate chemical 
tests to discover them. Albumin is occasionally found in the urine of 
adults after great exertion, and children apparently in good health may 
also excrete albuminous urine occasionally. " Cyclic Albuminuria" 
is a term used to express this condition. The cause of the albuminuria 
is not well understood but it appears and disappears with considerable 
regularity. It is a strange fact that the urine passed by these patients 
in the latter part of the day is usually free from albumin. This rule does 
not apply however to the urine of children approaching puberty, who 
may show a marked albuminuria for a time without otherwise evidencing 
departure from health. 

Pathologic albuminuria occurs in all forms of nephritis, in renal 
hyperemia — especially when secondary to diseases of heart, liver or 
lungs — in anemia, purpura, leukemia and other serious blood disorders; 
in pregnancy; febrile diseases; apoplexy, tetanus and epilepsy. It has 
been satisfactorily proven that any damage to the renal epithelium will 
cause albuminuria, and Edebohls cured a long-standing case by fixing 
a dislocated kidney with torsion of the ureter. Albumin may also be 
present in the urine when circulatory disturbances exist. The albumin 
found in the urine when pus is present cannot be looked upon as a true 
renal albuminuria. Exposure to cold may cause inflammation of the 
kidneys with accompanying destruction of epithelium and albuminuria, 
and quite often we can gauge the extent of the epithelial degeneration 
by the amount of albumin present in the urine. In all the conditions 
mentioned the albumin is derived from the blood (serum albumin); in 
measles globulin alone is found, and we do not yet understand the reason 
for its presence. 

It will be evident from the above that it is irrational to attempt to 
treat albuminuria; we must discover the reason for its presence and set 
ourselves to relieve the underlying pathologic condition. Constant 
and marked albuminuria without well-defined evidences of other organic 
disease may be looked upon as a proof of nephritis. Most writers deny 
the possibility of a physiologic albuminuria. 

Tests for Albumin:— The detection of albumin is not at all difficult. 
Nearly every practician possesses a urinary teste ase and is prepared to 
test urine at the bedside. The simplest test of all is of course by boil- 



HEMATURIA 64 1 

ing the urine after the addition of an acid, but Heller's test is infinitely 
more satisfactory and quite as simple. Into a test tube pour a small 
quantity of nitric acid and allow an equal amount of filtered urine to 
flow slowly upon it. A sharply defined opalescent or white ring forms 
at the junction of the two fluids if albumin is present. Patients taking 
copaiba, turpentine and other oleoresins may pass urine which will give 
a similar reaction though free from albumin. In these cases the addi- 
tion of a little alcohol will serve to dissolve the precipitate if non-albu- 
minous. A faint pink ring appears if uric acid is present in any quantity; 
heat causes this to disappear. 

Robert's Nitric Magnesium Test is, perhaps, the most efficient of 
all. One volume of colorless nitric acid is added to five volumes of a 
saturated solution of magnesium sulphate; this fluid is kept ready as 
"Test Fluid for Albumin." A small quantity of the mixture is poured 
into the test tube and the urine added as in Heller's test; the resultant 
ring is much more distinct, however. 

ACETONURIA 

Acetone appears in the urine in health in infinitesimal amount, and 
in observable quantities in diabetes, wasting diseases — starvation, phthisis, 
cancer, etc., — fevers, and occasionally diseases of the bowels. It is sup- 
posedly due to the high degree of albumin destruction; it is occasionally 
noted after etherization. Test for Acetone: Pour four c. c. of the sus- 
pected urine into the test tube; after rendering it alkaline with liq. potassa 
add three to five drops of a strong solution of sodium nitroprusside. 
The fluid turns red; add a few drops of concentrated acetic acid and if 
the color changes to purple acetone is present. 

HEMATURIA 

Blood in the urine may be caused by several widely different condi- 
tions. Its presence in small quantities is only to be detected by the 
microscope but when freely present it turns the urine to reddish brown 
or even black. In females we must always remember the possibility 
of contamination with menstrual blood and withdraw a specimen of 
urine with the catheter. Hematuria may be present after the trauma, 
catheterization, during the course of infectious diseases; in cases of vesical 
calculus, purpura, hemophilia, tuberculosis (of bladder), carcinoma 
(any portion of urinary tract), ulcer, infarction (renal), severe conges- 
tion of the bladder or mucosa of the urethra, prostatic disorders, syphilis, 



642 HEMATURIA 

gonorrhea and renal diseases. The exhibition of such drugs as can- 
tharides, turpentine, etc., may cause bloody urine. In some few cases 
there seems to be a congenital hematuria, several members of a family 
being afflicted. In all cases it is essential to discover the source of bleed- 
ing, and any treatment to be really effective must be based upon a clear 
understanding of the cause. Careful examination and questioning of 
the patient will usually serve to shed light upon the subject. In early 
life we would expect to find hemophilia (other signs plentiful), acute 
renal disease, tuberculosis, or cancer. In younger adults syphilis or 
gonorrhea must be looked for. In older people calculi, cancer, prostatic 
disease and stricture will have to be thought of as possible causes. 

The use of the cystoscope and ureteral catheterization will serve to 
reveal the source of bleeding in obscure cases. Blood from the kidneys 
is well mixed with urine, and if a renal tumor exists, rest does not serve 
to lessen the amount. Pain is referred to the lumbar region. In stone 
in the kidney the pain is apt to be excruciating but paroxysmal, and the 
blood appears at intervals; rest relieves the condition. The amount of 
blood is usually small. If infection occurs the general health is affected 
and we have symptoms of sepsis. In tuberculosis of the kidney a small 
amount of blood intimately mixed with the urine is found. The tubercle 
bacillus and pus will generally be present in a 24-hour specimen. 

Papillomata occasionally cause profuse bleeding; the cystoscope 
will reveal the condition often. Tuberculosis of the bladder resembles 
cystitis and is easily recognized. Here as in all cases where the bleed- 
ing is from the bladder or urethra the blood is bright red and appears 
in quantities at times. Pain is relieved by urination. 

Vesical calculi may exist without causing hematuria; on the other 
hand profuse bleeding may be present; blood here appears after urina- 
tion, which is apt to be stopped suddenly, pain in the glans penis is com- 
plained of in most cases. Prostatic disease is usually found after forty; 
the patient voids urine frequently and blood may flow at the beginning 
or end of the act of urination. In some old people varicose veins at the 
neck of the bladder set up dangerous hematuria. Examination is essential 
in each case. Several cases of hematuria have been reported after 
severe exertion. Bicycle and equestrian exercise may cause blood to 
appear in the urine; in these cases there is some degenerative condition 
of the mucosa and percussion over the renal region will usually elicit 
signs of tenderness. Parasites may also cause hematuria; the filaria 
sanguinis hominis and distoma hematobium being the known offenders. 

A fairly safe rule is that blood from the bladder is passed at the end 
of urination (distinctive symptoms of bladder involvement also present); 



HEMATURIA 643 

urethral bleeding is evidenced by blood passing before the urine or with 
it, and renal hemorrhage can be augured when the blood is intimately 
mingled with urine which presents a smoky or brown color; casts and 
clots also appear in some cases. 

Heller J s Test for Blood in Urine: — If suspected urine is boiled with a 
solution of caustic potash, phosphates are precipitated which appear red 
from hematin. The microscope and spectroscope also detect blood in urine. 

Treatment: — This evidently must vary with the condition causing 
the hematuria. In most cases rest is beneficial and demulcent drinks 
should be ordered. Certain cases sometimes puzzle the doctor; here 
the presence of blood is constant and yet no further signs of renal or 
other disease are discoverable. Renal hemophilia will perhaps best 
express this condition, which has recently attracted considerable atten- 
tion. The free exhibition of ergotin, adrenalin or hamamelin has cured 
in several cases, when at the same time measures have been taken to 
improve the general physical tone and regulate circulation. 

Having discovered the source of hemorrhage and taken steps to arrest 
it, the physician will naturally treat the cause. If calculi are known 
to exist we must discover their nature. Uric acid concretions will call 
for the free exhibition of calcium carbonate and salines, with free 
draughts of barley water. Phosphatic calculi will of course not be in 
any way influenced by calcium. Barley water, acidulated slightly, may 
however be given ad lib. For other treatment see " Calculi-Vesical." 
Gallic acid in 3-10-gr. doses has given good results, especially if aqua 
cinnamomi is given at the same time. Acid sulphuric maybe exhibited 
in cinnamon water with effect. The use of the oils of erigeron, eucalyp- 
tus, turpentine and santal is to be restricted to cases where the hemor- 
rhage is from the renal pelvis. These drugs should never be used in 
nephritis. Hydrastinine, gr. 1-12 with arbutin or asparagin gr. 1-3-1, 
is extremely effective when the hemorrhage is due to congestion, and 
the effect is enhanced if small doses of atropine are given also. The use 
of preparations of the suprarenal capsule (adrenalin, suprarenalin, etc.), 
must be carefully restricted; these remedies increase arterial tension 
powerfully, and therefore must not be given where vascular pressure 
is already too high. Small doses of pilocarpine have given excellent 
results in some forms of renal hemorrhage. Creosote exerts a decidedly 
beneficial influence in tubercular hemorrhage although eucalyptol is 
better, and in engorged conditions with diseased mucosa chimaphilin 
or hydrastine will prove rapidly helpful. In nearly all renal, vesical or 
urethral diseases the indicated remedies may well be given with a good 
preparation of corn silk (zea maidis) or triticum repens. Tonics are 



644 HEMOGLOBINURIA 

often called for. Nuclein with or without the arsenates of iron, quinine 
and strychnine, prepared blood-foods and digitalin, will of course sug- 
gest themselves. 

Vesical irrigation with solutions of hamamelis, hydrastis or pinus 
canadensis, are frequently of great service; a return-flow catheter should 
always be used and only two to eight ounces of the fluid allowed to be 
in the bladder in any case. 

External Applications of ice or of cold water over the kidneys when 
renal hemorrhage exists, and over the hypogastrium in vesical bleeding, 
will be of temporary use, but these applications should never be con- 
tinued long. Cupping (dry) is, sometimes to be thought of; the cups 
should be placed over the loins and used in congestive conditions only. 

In stubborn cases of vesical hemorrhage (ulceration, etc.,) a solution 
of silver nitrate gr. 10 to the pint will give relief, as also will a solution 
of alumnol or alum, gr. 2-5 to the ounce. Iron perchloride is also rec- 
ommended, the proportion being one dram to the pint. Sterile catheters 
and solutions are necessary. The persistent use of arbutin is very 
effective. Of late we have at our disposal a very simple but effective 
instrument called the Psychophore, which allows us to pass a constant 
stream of hot or cold water through the rectum. Iced water used in this 
instrument will often promptly stop prostatic hemorrhage. 

HEMOGLOBINURIA 

Here, while the urine presents the same aspect as when blood is 
present, we find upon examination with the microscope that no red-blood 
corpusles exist; hemoglobin alone being present. The urine may be 
pink, brownish, dark red or of a chocolate tint, and a sediment is depos- 
ited on standing. This consists of lithates with occasionally oxalate of 
lime. Just how the hemoglobin reaches the urine we do hot know, but 
it is supposed to be set free in the blood prior to reaching the uriniferous 
tubules. 

Hemoglobinuria is met with in three forms: toxic, paroxysmal and 
iniantile. The first variety is caused by the ingestion of drugs which 
exert a destructive influence upon the blood; phenol, pyrogallic acid, 
potassium chlorate, naphthol and muscarine are specially prone to pro- 
duce the condition, and we also meet with it in malarial fevers, scarla- 
tina, syphilis (occasionally) and typhoid; the toxins reduced during the 
invasion causing dissolution of the corpuscles. 

Paroxysmal hemoglobinuria is not a common disease but exists 
perhaps more often than is known. Extreme fatigue or exposure to a 



CHYLURIA 645 

cold rain, or falling into water, has caused the disorder to appear in cer- 
tain individuals. That some obscure dyscrasia exists in these individ- 
uals is evident, and a course of iron and arsenic has been known to 
prevent such attacks. Malarial toxemia has been credited with being 
the cause, but there is no definite proof of this and it is more likely that 
hepatic disturbance is primarily responsible. The symptoms vary greatly; 
some people feel cold and languid and the extremities are wrinkled and 
turn blue. Anemia seems essential in malarial forms. Others again 
have urticaria or purpura, well marked, or the skin becomes icteric. 
In these cases the temperature is as a rule subnormal, and the pulse slow 
and compressible. More or less pain in the loins and over the liver is 
complained Qf. The attack lasts a day or more but is apt to recur. 

Hyoscyamine is without any question the most effective remedy, 
and it should be given immediately upon appearance of the first symp- 
toms. Those subject to the disease should be carefully protected from 
cold and warned not to over-exert themselves. Nuclein and the arsenates 
will prove the best tonics, with alternate doses of quinine hydroferro- 
cyanite. Hydrastinine is also of service if continued for some time. 
Strychnine and capsicum with glonoin will cut short an attack. These 
remedies may be given with a hot drink, and the patient should have 
hot flannels applied to the body and be put to bed. 

One of the peculiarities noticeable in many cases is that the stools 
become black. Examination of the urine often reveals serum, albumin, 
hemoglobin and a few erythrocytes. Palpation will show some enlarge- 
ment of liver and spleen. A few doses of leptandrin and berberine, 
with fractional doses of calomel, followed by salines, speedily correct 
these conditions. In the intervals some albumin may be found in the 
urine. Glonoin gr. 1-250 every four hours will cause it to disappear 
and the exhibition of the remedies already suggested will prevent recur- 
rence. 

CHYLURIA 

This disorder is neither common nor well understood. One variety 
is due to the presence of the filaria sanguinis hominis in the blood; the 
ova of the parasite blocking the lymphatic communication between the 
distended vessels and some portion of the urinary tract resulting. Another 
form of chyluria exists however, in which fat presents in the urine with- 
out any discoverable cause. In chyluria the urine is milky and even 
a high-power microscope often fails to reveal fat globules, so complete 
is emulsification. Thymol in full doses is said to destroy the filaria, and 



646 OXALURIA 

eucalyptol has also caused the condition to disappear. Occasionally 
the urine coagulates in the bladder and it becomes necessary to break 
up the clot with a solution of sodium bicarbonate, thrown into the bladder 
through a large catheter with an aspirating syringe. The disease is 
scarcely ever seen in America. 

PYURIA 

Pus like blood may be present in the urine for some time without 
being detected. It may have its origin in the kidney, bladder, prostate 
or urethra, or be thrown into the urinary tract from remote abscesses. 
In every case the source of the pus must be discovered. In kidney dis- 
ease it is often so intimately mixed with the urine that only the microscope 
or addition of liquor potassa will reveal its. presence. When from the 
bladder or an abscess opening into the tract it is in flocculent masses 
or may be seen almost pure. 

In cystitis the urine is usually alkaline; in pyelitis or other disease 
of the kidneys accompanied by production of pus it is acid. Prostatic 
abscess is distinguished by the pain in prostatic region and glans penis, 
and the passage of unchanged pus. 

Treatment: — This naturally will be governed by the conditions pres- 
ent. The free use of calcium sulphide and the formates, or formin, 
will however be required in most cases. Urethral and vesical irrigations 
with H 2 2 , and mild solutions of the silver salts, will prove useful if 
the pus originates external to the ureters. In pyuria when the pus comes 
from the kidneys or flows into the bladder through a sinus it is posi- 
tively essential to irrigate in order to prevent, if possible, infection of 
the latter viscus, though the tolerance of the bladder mucosa to pus is 
well-known. In all cases, even the worst, the persistent use. of arbutin 
may be trusted to secure a cure. 

OXALURIA 

The presence of oxalate of lime in the urine is normal. About a 
grain is probably excreted by a healthy adult each day. The crystals 
are easily recognized, being octahedral and colorless in the majority of 
cases, but occasionally presenting in the "dumb-bell" form. Some writers 
seemingly overlook this condition, which is as a matter of fact a serious 
one, for the continuous appearance of oxalates in any quantity bespeaks 
metabolic disturbances which are inimical to health. 

Both oxaluria and phosphaturia are distinctly diseases of the quick- 
living modern American, and the physician should be ready to recognize 



' OXALURIA 647 

and stop the drain upon vitality which these conditions represent. The 
fact that many articles of diet contain oxalic acid, and that oxaluria is 
often present in people who consume such food in quantities, has been 
advanced as an argument against the existence of the oxalic diathesis. 
Vegetables, tea, cocoa, coffee and chocolate contain oxalic acid in greater 
or less quantity, spinach, rhubarb, cabbage, beets, potatoes and celery 
being particularly rich in the substance. Bread also has a certain pro- 
portion. The urine of the poor who eat the more common vegetables 
and drink bad tea abundantly is often loaded with oxalates, and these 
are the very people who can least afford to lose lime from the system. 

An excess of oxalates taken into the economy must of necessity result 
in the voidance of a greater amount of oxalate of lime in the urine, but 
as a matter of fact the oxalic diathesis is not found so much among these 
people as it is among the hard-working, nervous, middle or upper- 
class individuals who eat well — but fail to nourish themselves. 

As a matter of fact we do not know just where the oxalate of lime 
does come from, for oxaluria may occur in people who eat food contain- 
ing little or no oxalic acid, and here we almost invariably find marked 
malnutrition, nervous phenomena of all kinds, and dyspepsia. 

Take a patient who complains of pain in the back, weakness in the 
knees, lack of capacity to do things, nervousness, hysteria, irritability 
and loss of weight, with depression of spirits, and examine his urine, 
and it is probable that you will find oxalate of lime in quantities. It is 
altogether possible moreover that calculi will soon form in such cases, 
adding to the distress of the individual. That the oxaluria is due to 
deranged metabolism and causes ill-health is proven by the fact that 
proper treatment causes its prompt disappearance and a return to nor- 
mal conditions. 

That some urine deposits oxalates upon standing does not have 
any pathological significance. But if fresh urine shows day after day 
abundant oxalates, then there is nutritional disturbance w r hich must be 
corrected at once. Pain over the bladder is frequently complained of 
by these patients, and the complexion is as a rule sallow and the tongue 
mildly coated; constipation usually prevails. As uric acid is quite often 
also in excess in the urine of oxalurics the various disturbances which 
may arise can well be surmised. 

Treatment: — The first thing to do is to eliminate and restore general 
functional activity; the next to put the patient upon a generous mixed 
diet, insisting upon the consumption of plenty of meat, eggs, milk, etc. 
The exhibition of dilute nitrohydrochloric acid ten to fifteen minims 
in water after each meal, with strychnine, quassin or hydrastin before 



648 PHOSPHATURIA 

eating, will often prove effectual, causing the entire disappearance of 
the oxalates. Much more must be done, however, if we would maintain 
health. The patient should take a small quantity of sulphate of mag- 
nesia each morning upon rising and indulge in a cool sponge bath with 
salt water preferably; then he should take a short but brisk walk before 
breakfast, which should be eaten slowly and consist of fruit, cereal, a 
chop, or two eggs, and coffee with cream. Some gentle but thorough 
system of exercises will help unless the patient takes plenty of ordinary 
outdoor exercise — which is seldom the case. Cars should be interdicted 
and the office man or woman should be told to walk one way at least. 
One hour before each meal juglandin gr. 1-6, or boldine gr. 2-67, or a 
tablet of nux vomica and capsicum, will prove excellent, with in anemia 
iron phosphate gr. 1-6. Papayotin gr. 1-3-1-2 may be taken afer meals 
if digestion is impaired, or pancreatin and bilein combined will help if 
intestinal digestion alone is at fault — as it frequently is. Finally, twice 
a week these patients should take calomel gr. 1-10, podophyllin gr. 1-12 
hourly for four doses after supper. In from two to four weeks the result 
will be a gain in weight of from four to ten lbs., improved capacity for 
work and brightened disposition. Surely, something well worth working 
for. The patient should present himself for further treatment if at any 
time the old symptoms reappear; it is a good plan to have the urine of 
oxalurics examined every three months. When duodenal or gastric 
catarrh is present also, copper arsenite, gr. 1-100 before meals, is specific. 

PHOSPHATURIA 

We are confronted with two distinct forms of phosphatic urine; in 
the first amorphous phosphate of lime is deposited in the vessel after 
the passage of alkaline urine. The laity often mistake this for "gravel" 
and when the phosphate is deposited (as sometimes occurs) in the blad- 
der, and is voided at the end of urination, the whitish material is apt to 
be mistaken for semen or prostatic fluid, neither of which really resemble 
it in the slightest degree. Authorities differ as to the importance of this 
condition, but when calcium phosphate is constantly excreted in large 
amounts there must be a systemic drain and nervousness and debility 
result. 

Individuals presumably in perfect health sometimes void urine which 
upon heating precip tates calcium phosphate; it is not thought that 
calculi are apt to form in such cases but where the urine remains alkaline 
and the phosphates are found (upon making a quantitative analysis of 
the 24-hour output) to be present constantly in excessive quantity, it is 



PHOSPHA'ITRIA 649 

well to give ammonium benzoate and a course of alterative tonics for 
a few weeks. The diet should be changed and general hygienic condi- 
ditions improved; a daily sponge bath with a solution of epsom salt solu- 
tion (one ounce to the quart of water) as cool as is tolerable, followed by 
a brisk rub with a rough towel will do good. Fruit, fish (fresh), eggs 
and the glycerophosphates, or calcium lactophosphate, should be ordered. 
Quassin gr. 1-6, quinine hydroferocyanate gr. 3-67, and xanthoxylin 
gr. 1-6, before meals, with a good digestant like papayotin, after eating, 
will usually prove useful. 

A very useful formula is pulverized sulphur (resublimed) gr. 1-33, 
strychnine arsenate gr. 1-134, podophyllotoxin gr. 1-67, collinsonin gr. 
1-134, hydrastin gr. 1-67; this may be given after meals, three to four 
such granules being the usual dose. Nuclein solution, four to eight 
minims, may also be dropped under the tongue, morning, noon, and 
night. In advanced cases where there are distinct evidences of nerve 
instability phosphoric acid (dilute) five to ten minims, may be given even- 
four hours, or strychnine and phosphorus half an hour after food. 
Neuro-lecithin is also of service as a reconstructant. 

The phosphatic deposits in ammoniacal urine bespeak an entirely 
different condition. In cystitis urea is acted upon by a ferment (bacterial) 
and we get as a result the triple or ammoniomagnesium phosphates; 
there is more than a probability that calculi will form if this condition 
is present for any length of time; indeed, the entire bladder mucosa may 
be covered with a deposit something like the "scale" which forms in 
boilers. It remains a question as to how the bacteria gain access to 
the bladder but given a residuum of urine — the viscus failing for any 
reason to empty itself, and ammoniacal decomposition ensues. As a 
result, if a cystitis does not already exist the condition is soon set up, 
and pus soon presents in the urine excreted. Catheterization is perhaps 
most often responsible for the infection, few practicians not making a 
speciality of genitourinary work taking sufficient care to ensure asepsis. 
The dangerous habit of giving old men a catheter and allowing them 
to carry it about with them for use at any time and under any circum- 
stances, cannot be sufficiently condemned. If self-catheterization is 
essential, the instrument should be kept in a solution of formalin, and 
wiped off before use with a piece of cotton soaked with a solution of 
eucalyptol and olive oil — 1 part to ten. 

The treatment in this form of phosphaturia is that for cystitis, which 
see. It might be remarked here, however, that weak solutions of nitric 
acid used locally unquestionably dissolve phosphatic deposits and give 
great relief to the patient. One of the best preparations the writer has 



650 LITHEMIA: LITHURIA— "URICACIDEMIA" 

found is an aqueous solution of chloral and phenol. The two drugs 
are rubbed together and one dram of the resultant fluid is slowly mixed 
with a pint of distilled water. The bladder is drained and the fluid 
inserted through a rubber catheter, at a little above body-temperature. 
The patient is placed upon his back, abdomen and sides alternately, 
and the fluid is finally withdrawn. Three such treatments, following 
copious irrigation with boric acid solution, have cured some of the worst 
cases encountered in practice. Of late a solution of silver citrate (Crede) 
has been recommended. 

LITHEMIA; LITHURIA— "URIC ACIDEMIA" 

Lithiasis or the deposition of lithic (uric) acid and urates in the 
urine is a term widely and often wrongly used to express the uric acid 
diathesis, whereas it really describes that condition which leads to the 
formation of uric acid concretion. 

In gout, rheumatism and various other diseases we have a lithemic 
condition, excess of uric acid in the blood, and may have- lithuria ; though 
this does not necessarily follow, as there may be excessive formation of 
uric acid with retention. As soon as we get rid of the uric acid from 
the system — as such, or as amorphous or crystalline urates, we get amel- 
ioration of the symptoms caused by its presence. 

Lithuria then expresses that condition (usually lithemic) in which 
the urine contains an excess of uric acid or urates, and here there is a ten- 
tendency to lithiasis. Urine of this character is dark in color, heavy, 
and when cooled deposits a " brick-dust" sediment. Under the micro- 
scope uric acid is seen to consist of reddish-yellow rhombic prisms, or 
crystals of lozenge shape. Crystalline urates appear as needles, globular 
masses, or assume the dumb-bell form. 

Amorphous urates appear as fine, dark-colored opaque granules. 
All of these substances are supposedly derived from the nuclein of cel- 
lular nuclei, and the free exhibition of assimilable calcium salts with 
nuclein serves to enable the system to withstand the drain and institute 
reparative processes. Great destruction of the cells having taken place 
the system is invariably loaded with an immense amount of waste — 
dead matter — hence it becomes a favorable field for the propagation of 
various pathologic bacteria. Here briefly, is one of the great facts of 
medicine; and he who appreciates it and institutes rational therapeutic 
measures in his uric acid cases, is able to obtain results which hitherto 
were deemed impossible. The use of arsenic, which favors fatty meta- 
morphosis, is here intelligible. 



LITHEMIA; LITHURIA— "URICACIDEMIA" 651 

Test for Uric Acid: — Upon a small porcelain dish evaporate a little 
of the suspected urine, and after adding a few drops of nitric acid 
(Jortior) heat again to dryness. Cool and then add a drop of liquid am- 
monia; murexid is formed and presents a deep purple color. The urates 
appear in normal urine as quadriurates; in this form uric acid is physio- 
logic, and when a departure takes place we get various morbid phe- 
nomena. It should be remembered however that some departure from 
the normal must have occurred to cause the change in the body chemistry. 
Hence it remains a question, which still is earnestly argued, whether 
uricacidemia causes certain diseases or is caused by preexisting patho- 
logic conditions. 

It is probable that certain metabolic derangements tend to the for- 
mation and retention of uric acid, and the presence of this substance 
in the blood-stream unquestionably sets up various disorders which the 
physician is called upon to remedy. Rarely indeed is he sent for to cor- 
rect the wrongs which lead to uricacidemia — and unhappily when he 
is, he too often fails to recognize and treat them properly. We find 
increased urates in the urine of healthy men who have exercised exces- 
sively and perspired much; sometimes also there is an excess in diarrheal 
subjects. Free ingestion of nitrogenous food may also cause an exces- 
sive output of urates. In none of these cases has the excess any path- 
ologic significance. 

But when there is interference with oxidation or disturbance of 
metabolism, the presence of urates or uric acid in quantity means much. 
We find this excess in gout, high continued fevers, certain pulmonary 
diseases, leukemia and chronic indigestion. Prompt elimination, stimu- 
lation of the hepatic and renal functions and a limited chemically-correct 
dietary, will help us restore a normal state of affairs. In all such dis- 
orders the skin should receive attention and the excretory activity of 
the sudoriferous glands be accentuated. Daily salt or magnesium sul- 
phate sponge baths, followed by alcohol rubs, are exceedingly useful. 

The practician should remember that free uric acid is invariably a 
morbid product, met with as a crystalline body in the urine, and in the 
form of gravel or calculi in the urinary tract. Under certain circumstances 
the physiologic quadriurates (potash, soda and ammonia), which are 
extremely unstable, become decomposed in the body, uric acid is set 
free and as a result concretions are formed. Uric acid itself is extremely 
insoluble and concretions once formed are with difficulty disposed of. 

We are familiar with the fact that nearly all urine if kept from de- 
composition will sooner or later throw down uric acid. Were it not 
for the salts and pigments present in the urine which act as inhibitory 



6$2 LITHEMIA; LITHURI A— "URIC ACIDEMIA" 

agents uric acid would be voided generally and stone in the bladder 
would be as common as measles. 

The necessity for a sufficiency of saline constituents in the diet of 
sedentary people who live close is evident. Milk, meat, fish and fruits 
contain a large percentage of mineral salts, while bread, potatoes and 
oatmeal — the chief food of the poorer classes (together with meat of 
poor quality, often salted or smoked), are deficient in this direction. Trje 
well-to-do overeat often, and elimination in their case is generally wretched. 
They do not perspire or in any way stimulate oxidation, are apt to be 
constipated and thus throw a severe strain upon the kidneys. Hence 
we find nephritis most often among the very rich, or the poorly nour- 
ished indoor workers. 

Roberts says rightly: "High acidity, poverty in salines, low pig- 
mentation and high percentage of uric acid, tend to the precipitation 
of uric acid, while depressed acidity, richness in salines and pigments, 
and low percentage of uric acid, tend to retard precipitation. " 

In chronic nephritis we have urine of low specific gravity, almost 
devoid of color, and the absence of pigment here probably accounts for 
the tendency to precipitation of uric acid. This, of course, applies 
only to the interstitial form. 

In other chapters of this work the constitutional effect of excessive 
uric acid is considered fully, but it is well to state here that while in gout 
and other uric acid diseases the precipitation of acid takes place in the 
blood and tissues in the form of sodium biurate, in lithiasis, uric acid 
is deposited free while in an excretion still in contact with the urinary 
passages. The two processes are far from being identical, and in the 
latter disorder we should devote our attention to modifying the urine. 
In lithemia we must institute constitutional treatment and" correct the 
metabolic wrong which exists. 

During sleep and when digestive processes have ceased, the amount 
of urine secreted is reduced and the acidity increased. During the di- 
gestion of food opposite conditions obtain. We shall therefore find 
that the early hours of the morning are most favorable to deposition 
of uric acid as during sleep the urine is abnormally rich in urates and 
the urinary current slow and scanty. 

It is therefore desirable to have patients of this class take a glass of 
water containing five to ten grains of sodium or potassium bicarbonate 
on retiring; and on waking a saline is indicated. Magnesium sulphate 
is especially useful. If rheumatic or gouty tendencies exist also the 
addition of colchicine and lithia will be desirable. Salithia is therefore 
an almost ideal saline here. 



ACUTE DESQUAMATIVE NEPHRITIS 653 

Potassium citrate is not preferable, as many practicians think, as it 
is essential to relieve the gastric acidity which almost always is present 
in lithemic conditions. 

Small meals often are to be preferred, as the urine after food is usually 
rendered alkaline, and if we give with meals a little milk and water, or 
better still milk and barley water, slightly salted, we shall have done a 
good deal towards preventing the formation of uric acid. The patient 
should consume a reasonably large quantity of either pure or slightly 
alkaline water during the day, but calcium carbonate with lithia and a 
minute quantity of colchicine, as combined in Calcalith, will prove the 
best medicinal agent in most instances. Ten to twenty grains may be 
exhibited every four hours, with a glass of water. Exercise, the Epsom 
salt bath and general hygienic measures, have been already mentioned. 
It may well be mentioned here that German clinicians have recently 
obtained some almost phenomenally good results in lithiasis, from the 
exhibition of large doses of glycerin; from one to four ounces is exhib- 
ited with an equal quantity of water, between meals, for several days. 
The urine becomes oily, the specific gravity is raised, and in most cases 
pain ceases promptly. Calculi were voided in over 60 per cent of the 
cases treated. 

ACUTE DESQUAMATIVE NEPHRITIS 

This is an acute inflammatory process which involves particularly 
the lining epithelium of the renal tubules and glomeruli. The three 
varieties are tubular, glomerular and interstitial, but it is as a matter 
of fact impossible to distinguish one from the other clinically. 

Pdthology: — The kidney, post mortem, is found to be swollen and 
the capsule is non -adherent; early the organ is deep red but later becomes 
mottled though the Malphigian tufts retain their deep red tint; the 
tubules are blocked with desquamated epithelium, blood-corpuscles and 
serum-albumin; the vessels are dilated, their walls degenerated and 
extravasations of blood are not infrequent. The cloudy swelling which 
first affects the epithelium later becomes a distinct fatty degeneration. 
The interstitial tissue is infiltrated with leucocytes in abundance. 

Patients seldom die early, but from the few cases examined it would 
seem that there is intense hyperemia with inflammatory exudation con- 
taining red blood-corpuscles and leucocytes. Circulation in the Mal- 
phigian tufts is interfered with and nutrition suffers, the epithelium of 
the glomeruli swells and undergoes fatty degeneration, and finally the 
convoluted tubules become more or less occluded with the products of 



654 ACUTE DESQUAMATIVE NEPHRITIS 

inflammation and waste. Excretion is lessened — sometimes stopped — 
and toxins which should be excreted in the urine are thrown back into 
the blood. 

Etiology: — Acute nephritis may be caused by exposure to cold and 
wet, pregnancy, the acute infectious diseases (especially scarlatina), the 
ingestion of poisonous drugs (turpentine, copaiba, cantharides, phenol), 
extensive burns or skin diseases, and alcoholic excesses. Occasionally 
it is impossible to account for a nephritis. 

Symptoms: — These are at first . vague but later distinctive. Usually 
there is some rise of temperature, but occasionally this feature is lacking 
till late. There is pallor with puffy swelling of the face (especially about 
the eyes on rising in the morning), edema of the ankles, lumbar pain, 
nausea and sometimes vomiting. Chills and rigor may be present. 
Anemia increases steadily. The dropsy, headache, furred tongue and 
anorexia, together with obstinate constipation complained of by patients 
with well developed cases, only too frequently presage uremia. 

The urine is scanty (it may be entirely suppressed), smoky or high- 
colored, with a sp. gr. of 102 5-1030, and contains albumin, blood-cor- 
puscles and epithelial, hyaline and blood casts. Some granular casts 
may be noted also. The output of urea is markedly decreased. 

Occasionally we get pronounced and diffused anasarca, typical urine, 
and all the symptoms of the disease, and yet improvement is noted daily 
even under indifferent treatment. 

But when the skin is dry and harsh, and effusion takes place into 
the serous cavities, and we find the aortic second sound augmented, we 
can only offer a guarded prognosis. In some cases an examination of 
the urine alone will reveal the disease, and in pregnancy uremic convul- 
sions often give us the first knowledge of its existence. 

In the vast generality of cases the symptoms are for a time slight, 
even when the urine is markedly pathologic. History, and the absence 
from the urine of fatty casts, will enable us to distinguish an acute from 
an exacerbation of chronic parenchymatous nephritis. 

Prognosis: — Always guarded. Uremia may develop suddenly and 
kill. In severe — or rather typical — cases, death may follow from ex- 
haustion or edema of the lungs. The disease may become chronic. As 
a rule acute nephritis runs its course in from two to six weeks, and ends 
in recovery. 

TreBtment: — Rest and milk diet will save many cases if seen early 
enough. If we are called only when urine is suppressed, or uremic 
toxemia threatens or exists, we must institute heroic eliminative meas- 
ures. These are fully described under the head of " Uremia." 



ACUTE DESQUAMATIVE NEPHRITIS 655 

A clear conception of the conditions present will enable us to take 
effective therapeutic steps. First we must endeavor to divert the blood 
from the congested kidneys; relieve the strain upon those organs by 
increasing the activity of the skin and bowels, and flush the tubules with 
non-irritating fluids. At the same time it is well to remember that the 
system itself is loaded with toxic matter which requires removal before 
normal functionating can be looked for. 

By exciting the intestinal mucosa and skin to double duty we not only 
lessen the work of the kidneys but also divert a large proportion of the 
blood, while at the same time we get rid of retained urinary excreta and 
reduce vascular tension. Under ordinary conditions then we shall give 
small doses of atropine to relieve congestion and flush the capillaries; 
exhibit salines, subsequent to small divided doses of calomel and podo- 
phyllotoxin (gr. 1-6 each every hour for four doses every other day) to 
insure free watery stools; and also give veratrine and glonoin with benzoic 
acid with free draughts of water to flush the tubules and remove epithe- 
lial debris. The patient is sponged twice daily with a solution of mag- 
nesium sulphate, one dram to the quart of water. Three pints of milk 
should be consumed daily, the patient chewing each mouthful before 
swallowing it. High enemata of weak saline solution are given morning 
and night, and gr. 1-67 of strychnine nitrate, or brucine, exhibited every 
four hours. In many cases this will be all the treatment required, though 
it is usually well to add nuclein in eight to ten-drop doses three times a 
day. 

In cases where urine is scanty and dropsy distinct, we may perhaps 
take more energetic steps at once. The patient is placed in the wet pack 
or hot bath — the pack however being infinitely more efficacious, as de- 
scribed in the chapter on uremia. Pilocarpine may be injected hypo- 
dermatically — gr. 1-10 to 1-6. At the same time the exhibition of elaterin 
is begun; gr. 2-67 every hour for four doses. Menthol gr. 1-12 should 
be given with each dose. After one hour, the patient having per- 
spired profusely an enema may be given (which should be voided into 
a bed-pan) and the patient placed in a warm dry bed. The elaterin 
should be continued till four doses have been taken. Free watery 
stools will follow, and the treatment already outlined will as a rule serve 
to maintain the effect. However in some cases apocynin may be necessary; 
gr. 1-6 every three hours. A hot bottle or mustard plaster may be 
applied over the kidneys if pain is complained of, but the osmotic glyc- 
erinized pastes now employed are much more satisfactory. Harsh 
purgatives are rarely if ever admissible. Salines and the drugs mentioned, 
with enemas, will do all that can be done. Where the pulse is full 



656 CHRONIC DESQUAMATIVE NEPHRITIS 

and bounding, vera trine in small repeated doses speedily gives results; 
gr. 1-134 every half -hour for four to six doses usually suffice. Where the 
arterial tension is low and heart-action labored and feeble, caffeine may 
be employed, best hypodermatically in a solution of sodium ben- 
zoate. Gr. 3-5 caffeine with a like quantity of sodium benzoate should 
be dissolved in thirty minims of distilled water and injected. The use- 
fulness of cactin must not be forgotten. This drug strengthens the 
heart-muscle by increasing the circulation in the coronary arteries, and 
also exerts a direct stimulative action upon the vasomotor and spinal- 
motor centers. 

Cactin acts directly upon the cardiac plexus, increasing the contractile 
energy of the heart and improving its nutrition. It is the heart-tonic 
of choice where we seek strength without irritation — gastric or cardiac. 
This drug may be depended upon in the later stages of nephritis — not 
as a diuretic, for it possesses no distinct diuretic action — but 
as a cardiac brace which will serve to maintain life while we 
combat the toxemia which threatens to destroy vitality. Gelsemi- 
nine and chimaphilin are two useful drugs in acute nephritis. 
The first should be given in small doses (gr. 1-250), when the eye is 
bright, the skin dry, the urine scanty and red and face flushed, with a 
quick, small pulse. Alternated with strophanthin or sparteine the skin 
moistens, the pulse becomes soft and copious discharges of urine occur. 

Arbutin and eupatorin (the latter the active principle of the old fami- 
liar " bone-set" of our grandmothers), may be given with water, several 
times daily, after the more urgent symptoms have been controlled; gr. 1-6 
of each will prove the most useful dose, repeated every 2 to 4 hours. 
Nephritic patients should wear flannel next to the skin and avoid sudden 
changes of temperature; the lungs should always receive careful attention, 
as not infrequently they become affected. 

In extreme cases it may be necessary to make incisions in the tissues 
about the ankles. Southey's tubes (small silver canulae) are often inserted, 
but as a general thing multiple scarifications through the skin will suffice. 
Iron arsenate, quinine and strychnine, or brucine, will be the best tonics 
for the recovering patient. The writer gives also a pill containing iridin 
(from Iris versicolor), eupurpurin (from eupatorium purpureum), eupa- 
torin and apocynin, a a gr. 1-12, four times daily for several weeks. 

CHRONIC DESQUAMATIVE NEPHRITIS 

This is the tubal or catarrhal type of nephritis, represented in the 
early stages by the large white kidney, later by the small white or con- 



CHRONIC DESQUAMATIVE NEPHRITIS 657 

tracted form. The large red or variegated kidney is a hemorrhagic 
form. This sometimes follows acute nephritis of scarlatina or pregnancy, 
but more frequently arises de novo, its origin and beginning being wrap- 
ped in obscurity. Young men are more liable, especially the drinkers 
of beer. Exposure to cold and wet have been noted in connection with 
it, and have been assumed to be causative, without proof. More prob- 
ably the continued action of blood toxins is responsible, the delicate 
textures of the kidneys being unable to withstand such irritation for 
unlimited periods. 

The symptoms are insidiously developed, and frequently the patient 
has no suspicion that his kidneys are affected until it is revealed by a life 
insurance examination. In other cases there is a growing tendency to 
anemia, debility, anorexia, dyspepsia, headache, dullness, pallor, the 
patient retaining his weight but losing his color, the face becoming pasty 
and pimply, the body flabby. In other cases the man may be the picture 
of ruddy health, bright eyed and happy. Edema appears at evening 
about the ankles, or the patient finds his shoes uncomfortably tight then, 
and in the morning his eyelids are swollen. The urine is slightly de- 
creased, increased or normal in quantity, the s. g. corresponding. Exam- 
ination discloses the presence of albumin in moderate or large quantities, 
with casts, epithelial at first, becoming fatty and hyaline as the tubes 
are deprived of their lining. Edema increases and may become general. 
Dyspnea occurs from the toxemia long before it is occasioned by the 
filling of the thoracic serous cavities. Bronchial and other catarrhs 
are common. Uremia is not a usual phenomon in this form. Neuro- 
retinitis is frequent in advanced stages. The tightly stretched skin of 
the legs may become eczematous or erysipelatous if broken or cut. The 
course depends largely on the treatment. Properly managed, with an 
obedient patient and suitable means, it need not shorten life. This 
is not the prognosis of the textbooks, but the following case is significant: 
In 1877 the writer attended a case, diagnosed as desquamative nephritis 
by S. Weir Mitchell; the lady is still, in 1906, enjoying good health. 

The diagnosis is made by the presence of a medium quantity of albu- 
min with epithelial and granular casts, later becoming fatty and large 
hyaline, with the progressive anemia and hydremia described. Methy- 
lene blue is arrested in the kidney and not eliminated by it as in health. 

The writer clings to the milk treatment, which has afforded him 
satisfactory results in this form of nephritis for a third of a century. The 
patient must be restricted to skimmed milk alone, a half glass every four 
hours, night and day, half an hour to be consumed in the mastication 
and ingestion of this quantity* At first the patient will feel as if this was 



658 CHRONIC INTERSTITIAL NEPHRITIS 

not enough to sustain life, and he may take more if he takes it in the 
manner and time prescribed; but biliousness will soon warn him of excess, 
and he will settle to about the quantity suggested. The milk is to be 
taken with a teaspoon, and each spoonful held in the mouth and chewed 
until thoroughly incorporated with saliva. As the milk grows distasteful 
it may be varied by substituting fresh sweet buttermilk, junket, whey, 
or koumiss, in similar quantities. Once a day instead of milk an equal 
quantity of freshly pressed fruit juice may be taken. Water may be 
drank also if the dropsy does not forbid. This regime is to be sustained 
until the albumin has disappeared from the urine for one month, when 
we may begin cautiously adding small quantities of the simplest foods, 
such as toasted stale bread, zwieback, crackers, rice and other carbo- 
hydrates. The fruit juices may be increased also, and a little coffee 
allowed. Following these if albumin does not reappear, the order 
in which foods are to be added is: Fresh fruits and vegetables but not 
any that contain volatile oils like cress or oxalic acid like tomatoes; 
eggs, fish, oysters, chicken, turkey, beef, mutton; pork, veal, dry beans 
and peas as well as cheese being long prohibited. Alcohol is to be left 
forever out of the nephritic's diet list. 

The writer believes that the daily use of one to three grains of arbutin, 
and as much benzoic acid, has an influence in gradually restoring the 
diseased epithelium to health, and this is the only direct or dominant 
medication advised. High . tension is not common but demands the 
addition of just enough veratrine to restore normality in this respect. 
Low tension and debility may require sparteine or digitalin. Anemia 
calls for iron phosphate, a grain a day in the drinking water. Basham 's 
mixture is advised by every textbook, but we have never been able to find 
a physician who could testify to benefit derived from- it. Beyond this 
the treatment is that of symptoms, and of intercurrent maladies. The 
presence of red blood cells in the urine is met by the arbutin amply. 
The bowels must be swept out daily by a morning saline, as 
toxins from retained feces cannot but work disastrously on the diseased 
renal tissues. 

CHRONIC INTERSTITIAL NEPHRITIS 

We have here to deal with a malady in which the connective tissue 
develops at the expense of the cellular structure, a true hyperplasia and 
cirrhosis, in fact. The kidney is small and contracted r the cortex com- 
posed largely of hyperplastic connective, the pyramids also contracted. 
The arteries are sclerosed, the heart hypertrophied. ::.,: 



CHRONIC INTERSTITIAL NEPHRITIS 659 

The malady begins in midlife, more in males, is hereditary; follows 
uric acid, lead and alcohol poisoning, syphilis and malaria, and the tox- 
emia seen in those who habitually eat and drink too much, the gouty, 
rheumatics, and persons over given to worry and anxiety. The cold 
moist climate of New England and the Middle States conduces to it. 
(Purdy.) 

This form of nephritis is even more apt to be latent than the preceding. 
Evidences of uremia may suddenly develop during some intercurrent 
fever, or independently, or after some unusual exertion or exposure to cold 
and wet. But headaches have been common, with dizziness, anorexia, 
debility, perhaps unpleasant force in the heart-action or throbbing of 
the arteries, all of which may become evident to the patient's sensation. 
Nausea, dyspnea, a tense wiry pulse, and sometimes convulsions of petit 
mal type and unnoticed by the patient, may occur. After an attack of 
uremia the symptoms increase and debility becomes more evident. 
Urination is more frequent, and the sight fails. Spasms of dyspnea — 
renal asthma — occur. The urine is increased in quantity, pale, the 
s. g. falling perhaps to 1002, with never more than a trace of albumin 
and often not that, the excretion of solids being scanty. There may be 
a few hyaline or granular casts and leucocytes. The freezing point of 
the blood is lowered by the presence of substances not excreted, the 
arteries are like cords, the heart hypertrophied. The second aortic 
sound is accentuated. Epistaxis is common. Edema may suddenly 
occur, over night, in parts where the local obstruction theory will not 
apply — in the larynx, ear, prepuce, lip, lungs, etc. Occurring in the 
brain it may cause coma, but we cannot accept the theory that all uremic 
coma is due to this cause. The dyspnea increases in frequency and 
is worse at night. Cerebral apoplexy or pulmonary apoplexy may occur. 
Retinitis may be an early symptom. Tinnitus, deafness and vertigo 
are common. Diarrhea may give relief for a time. 

The diagnosis is made by the tense pulse, hypertrophied heart, and 
urine of low specific gravity and scanty excretion of urinary solids. The 
absence of albumin and scarcity of casts are significant. The occurrence 
of uremic symptoms in persons deemed healthy is to be noted. Epi- 
staxis in middle aged or elderly men who have lived better than wisely 
should lead to an investigation of the renal excretion. 

The prognosis is uncertain and should be guarded. Life may be 
prolonged for years, but the patient may at any time suddenly develop 
uremia or fall with apoplexy. Progressive symptoms are ominous. 

The treatment seeks first to raise renal excretion to the highest point 
possible to the scanty remains of renal tissue. The bowels must be 



660 CHRONIC INTERSTITIAL NEPHRITIS 

kept free and disinfected, the use of foods containing irritative substances 
excluded, especially the volatile oils, alcohol and meat extractives. Cut 
out condiments and spices, eat little meat and that best boiled, without 
the soup. Milk in all forms is good, and fruit juices; carbohydrates 
in moderation, albumenoids always sparingly, alcohol — shun as you 
would a rattlesnake. Take to the skimmed milk diet whenever uremia 
threatens. 

The great remedy is veratrine. This should be taken in doses suffi- 
cient to restrain the vascular tension as closely as possible to the normal 
point. Nothing better illustrates the superficiality of the ordinary pro- 
fessional knowledge of therapeutics than the unaminous advocacy of 
the nitrites for this indication. None of them exerts an action sustained 
more than a few minutes, and this is unsuitable for a malady where such 
action should be sustained for months and perhaps years. Veratrine 
enables us to do this with certainty and without a single disadvantage. 
It is sure, safe and devoid of all unpleasant effects. The dose is gr. 1-134 
well diluted, every half hour when uremia threatens and every mealtime 
in ordinal*)'' times, increased until the desired effect is secured. The 
local irritant effect is manifested by a sense of warmth marking out the 
limits of the stomach, and this usually indicates the presence of acute 
catarrh. Veratrine so fully covers the indications whenever abnormal 
tension is present that there is scarcely a variant needed. Syphilis and 
malaria call for their own remedies. 



/ 



PART VIII. 

DISEASES OF THE NERVOUS 

SYSTEM 



I. DISEASES OF THE PERIPHERAL 

NERVES 



NEURALGIA 



Neuralgia is a malady characterized by periodic paroxysms of pain 
affecting the course and distribution of one or more nerves, tending to 
recur in the same nerves and gradually extend to others in proximity or 
on the opposite side, inveterate cases being attended with the develop- 
ment of tenderness at the points where the affected nerves pass through 
bony or fibrinous foramina; also with patches of cutaneous anesthesia, 
and trophic changes in the affected integument. 

Etiology. — A predisposition to neuralgia exists in the neurotic de- 
scendants of drunkards, syphilitics, consumptives, the insane, or in fact 
of any persons affected with neurotic or cachectic disease. Any mode 
of life which leads to mental or physical debility increases or arouses the 
predisposition to neuralgia. In like manner, any cause of mental or 
physical depression is capable of bringing on a paroxysm, the tendency 
increasing with each. Any nerve in the body may be affected by neur- 
algia. The attacks at first occur on one side only. If one nerve of the 
face is thus affected neighboring nerves may in time be similarly attacked 
until the entire half of the face is throbbing with exquisite agony; or the 
same nerve on the opposite side may be affected in time. Nerves fre- 
quently thus affected are the supra and infraorbital, maxillary, facial, 
great occipital, intercostal, intercostohumoral, cardiac, lumbar and sciat- 
ic. Affecting the skin, the irritation may occasion an afflux of blood 
which is sometimes mistaken for erysipelas. Affecting the optic nerve, 
the trophic changes may impair or destroy vision. The pain is usually 
sharp and lancinating. Pressure gives relief, excepting at the painful 
points above mentioned. Tactile sensation is diminished over the affect- 



662 NEURALGIA. 

ed area. The paroxysms may last a few hours or continue for days, tend- 
ing to become more prolonged until they may be finally continuous if not 
relieved. The domain of neuralgia has been markedly circumscribed 
of late, since careful study has shown that in many instances the pain is 
dependent upon local lesions, such as tumors, spiculae of bone and other 
substances infringing upon the nerve in some portion of its course. Many 
other cases have been found to be dependent upon autotoxemia, which 
indeed is one of the most potent causes of true neuralgia. It is prob- 
able that in every case of this malady, however, there may be found de- 
generation of the posterior roots of the nerves involved. The painful 
spots are easily explained: The irritation due to the pain results in an 
afflux of blood, and this hyperemia gradually develops hyperplasia of 
the connective tissue elements, and as the lumen of the foramen remains 
the same, the nerve is pinched, and tenderness with tendency to contin- 
uous pain gradually develop. 

Facial neuralgia is more frequent in women and is frequently caused 
by cold and wet. Tic Douloureux signifies a very severe form of this 
malady, often accompanied by facial spasm. There is usually some 
neuritis in the branches of the fifth nerve and degeneration of the Gasser- 
ian ganglion. Intercostal neuralgia is especially common in women, 
attending myalgia of the intercostal muscles, due to degeneration caused 
by the use of the corset. In herpes zoster we have an eruption of small 
vesicles in the skin to which the affected nerve is distributed in addition 
to the neuralgic pain. The neuralgic skin is sometimes exquisitely sen- 
sitive. Affecting the heart the disease is known as angina pectoris. This 
malady is treated at length in the section on heart-diseases. Affecting 
the sciatic nerve it is known as sciatica. In many cases of this malady 
the rectum presents spasm of the sphincter, hemorrhoids, ulcers, fis- 
sures, fistulas or other lesions. Neuralgia of the anterior pleural nerve 
is less common. Visceral neuralgias are obscure and doubtful. Most 
of the cases formerly so called are now known to be symptomatic of struc- 
tural lesions. Each of these is treated in the section devoted to diseases 
of that organ. 

The diagnosis of neuralgia is important and not difficult. A parox- 
ysmal, non-inflammatory disease, at first unilateral, tending to recur in the 
same nerve, spreading in time to other allied nerves, developing in time 
anesthetic patches and painful points, induced by any cause of depres- 
sion and attended by trophic disturbances, without ascertainable local 
disease. The disease is to be distinguished from rheumatism, myalgia, 
neuritis, and the pain due to structural lesions infringing upon or 
transmitted along nerves. 



NEURALGIA 663 

The prognosis is better the earlier the neuralgia is recognized, its true 
nature and causes comprehended and effective treatment instituted. Many 
cases end in the slough of alcohol or the morphine habit. When the dis- 
ease has become inveterate a cure is more difficult, yet we doubt if there 
be such a thing as an incurable neuralgia. 

TreBiment: — The causal treatment is to be based upon a study of the 
case. The special causes are to be removed, the strength of the patient 
invigorated by whatever measures may be indicated. We thus find our- 
selves called upon to treat anemia on the one hand, the various dyspas- 
ias on the other. We have to regulate the digestion, following Anstie's 
suggestion that neuralgics require one-third more food than ordinary 
persons, but adding to this that the food to be beneficial must be digested 
and assimilated. By keeping the bowels clear of fecal accumulations 
and disinfected, by regulating the diet and insuring the proper digestion 
of the food, by insisting upon proper excercise, bathing and other points 
of personal hygiene, we cut away the foundation upon which neuralgia 
is built. When we have reason to believe that degeneration of the nerve 
roots is present, and Anstie claimed it was always present, the phosphide 
of zinc is a specific. To an adult give gr. 1-6 four times a day, at least 
one hour before meals or three hours after meals, and within two days 
the benefit will be manifest. Besides this, iron, quinine, strychnine, 
cod-liver oil, arsenic, and nitrohydrochloric acid are each useful when 
taken in the intervals, by patients whose condition requires one or more 
of these remedies. We do not believe in specifics for neuralgia, but we 
do believe in specifics for the cases in which each of these remedies is in- 
dicated specifically. 

We now come to the treatment of the paroxysms: Begin by clearing 
out the stomach and bowels; apply warm applications to the affected 
region; in some cases cold gives greater relief, although this is unusual. 
A mild galvanic current is one of the surest means of securing prompt 
relief, but only when applied in the following manner: Supply the pa- 
tient with a five-cell battery and instruct him as to its application. When 
he is seized with the paroxysm let the positive pole be applied to the pain- 
ful region, the negative being applied indifferently to any other part, and 
pass the current through until relief follows. The pain will recur in a 
short time, when the current is to be reapplied; and this is to be continued 
until the paroxysm has been extinguished. I have thus treated a neural- 
gia of such gravity that a morphine habit of ten years' duration had been 
established. If untreated the paroxysm would endure for a week until 
the patient was forced to resort to morphine, but by the use of galvanism 
the paroxysm was broken within 24 hours. The first required more than 



664 HEADACHE 

thirty applications of the current, but each succeeding one required less 
until two or three sufficed. 

When the skin is cool and shrunken, the pulse tense and contracted, 
the patient depressed and the pain intensified by light and noise, the rem- 
edy is hyoscyamine, gr. 1-500 in a spoonful of hot water, repeated every 
five minutes until relief or dryness of the mouth occurs. By this remedy 
the vasomotor spasm is relaxed, the blood released from the engorged 
centers and returned to the skin. Very severe and obstinate attacks 
are also broken up by zinc phosphide, strychnine arsenate and quinine, 
given separately or together in full doses. These remedies completely 
obviate the necessity for the use of opiates or the depressing coal-tars in 
the relief of neuralgia. 

Whenever the painful point can be made out, relief will be afforded 
by a blister placed exactly over the foramen. This is especially the case in 
dealing with sciatica, although here the first indication is to treat the rec- 
tal malady. It will also be found in inveterate sciaticas that the nerve 
is encumbered by lymph exudations, and these should be removed by 
persistent massage and the use of the most powerful absorbents. Lum- 
bago may be neuralgic, but is nearly always myalgic. Intercostal neur- 
algia usually combines both elements. Here great benefit is experienced 
from massage with hot cod-liver oil in case of emaciation, and the appli- 
cation of a mild faradic current, the positive pole, the current too mild 
to cause pain. By these means a fair amount of development may be 
afforded to the degenerated muscles and nerves, if the corset is laid aside 
and judicious exercise also employed. 

In the treatment of neuralgia better success will be attained if the 
remedies employed are administered at once in full doses, whereas if tim- 
idly dribbled into the system the body will become habituated to them 
without making much impression upon the disease. It will also be found 
that when a paroxysm has been promptly and effectively treated the next 
one will yield more readily, especially if proper hygienic measures have 
been adopted in the interval. 

HEADACHE 

The causes of headache are so multifarious that a list of the more 
common ones only can be given. These include toxemia from over- 
work, infectious diseases, tea and other external drugs, autotoxemia in 
all its phases; anemia and hyperemia, organic disease of the brain or its 
membranes, neuralgia; reflex irritation; passive congestions; and in- 
sufficient elimination. Perhaps the most common form is migraine, or 



MENIERE'S DISEASE 665 

sick headache. This is an autotoxemia, sometimes of neuralgic type 
but more frequently bilateral or affecting the entire cranium. The pa- 
tient awakes with a feeling of heaviness or depression, a dull pain about 
the eyes extending through to the occiput. The origin is generally de- 
noted by bad breath. The pulse is small and contracted, of cord-like 
tension, the skin and extremities pale and cool, the pupils contracted. 
The pain gradually increases, being rendered worse by light, sound or 
motion. Towards the middle of the day the tension relaxes and the face 
may flush somewhat, the pain assuming a throbbing character so that 
the patient frequently speaks of splitting the head open to get relief. At 
the point of greatest depression there is apt to be nausea or even vomiting; 
and if this occurs spontaneously relief gradually ensues. While this is 
due to the absorption of toxins from the bowels it is not directly relieved 
by cathartics, whose first action being to liquefy the stools, toxin absorp- 
tion is increased. Nevertheless it is impossible to get rid of the offending 
matter without emptying the bowels. It would seem, therefore, that the 
most direct method of giving relief would be to administer charcoal, which 
would absorb the toxins in the stomach and upper bowel, inducing cathar- 
sis meanwhile by the use of strongly exosmotic enemas, such as an ounce 
or two of pure glycerin, or eight ounces of saturated solution of table salt, 
either of which if thrown into the colon will promptly excite exosmosis 
and catharsis without favoring absorption from the bowel into the blood. 
A very effective temporary remedy is a hot mustard foot-bath, which re- 
lieves the cerebral congestion and often completely stops the pain, giv- 
ing the patient relief until elimination can be effected. Prevention lies 
in the proper regulation of the diet and personal habits. 

Headache is never a disease, but always a symptom and a symptom 
whose treatment is so absolutely that of the cause of disease that we deem 
it unwise to further consider these cases separately. 

MENIERE'S DISEASE 

This is a disease of the labyrinth of the internal ear, of the auditory 
nerves or its centers, with progressive deafness and vertigo. The nerve- 
ends may be inflamed or atrophied. It is rare before 30. 

Vertigo is the most prominent symptom and is quite marked. Tin- 
nitus is also present. Great difficulty in walking is experienced, the 
dizziness increasing whenever the patient rises. The general health 
fails also. There is anorexia and sometimes persistent vomiting. When 
the deafness har become complete the vertigo ceases. Nystagmus, dip- 
lopia and brief loss of consciousness may occur. 



666 DISEASES OF THE CRANIAL NERVES 

The diagnosis is easy. The prognosis is doubtful and becomes worse 
as the disease progresses; the general health improves when deafness 
becomes absolute. Some cases recover. 

Treatment: — Quinine has proved useful; begin with small doses 
and continue until cinchonism results. Solanine would probably prove 
useful. Hirt recommends pilocarpine, and Zinckler ergot. Either 
drug should be pushed to full physiologic effect. Zinc phosphide should 
be tried to. combat the degeneration. Eliminate, apply blisters over the 
mastoid process, treat any cachexia present. Gowers advises salicylates. 
Anders suggests apiol and glonoin. The alimentary canal must be 
emptied, disinfected, and kept clear and clean. 

DISEASES OF THE CRANIAL NERVES 

The olfactory nerve may be irritated by a tumor or other cause of 
compression. This may occasion hyperosmia or increased sensitiveness 
of the nerve, while any destructive process causes anosmia. Perver- 
sion of the sense of smell is sometimes manifested. The diagnosis 
is as to the cause of the symptom. The prognosis and treatment depend 
also on the cause. 

Optic neuritis attends most tumors of the brain. Optic atrophy may 
be primary or secondary to degenerations of the nerve root, such as occur 
in ataxia. Atrophy dependent on neuritis is usually preceded by choked 
disk. Hemianopsia is generally due to unilateral lesions in the optic 
tract. Wernicke's sign, inaction of the pupil, indicates a centric lesion, 
but if this is behind the thalamus this sign will not be present. Lesions 
involving the outer fibers of the tracts passing to the optic nerve cause 
binaural hemianopsia. The bitemporal form results from destruction 
of the anterior fibers of the commissure, as in acromegaly, while the hori- 
zontal form is caused by an affection of half the nerve or tract above or 
below, producing blindness in the upper or lower field. Hemiopia in- 
dicates disease of the retina on the same side. Hemeralopia is due to 
retinal disease; nyctalopia is generally syphilitic. 

The treatment mainly depends upon the cause. Galvanism is some- 
times useful. A popular remedy sometimes useful consists in plunging 
the face into a basin of cold water and opening the eye so that the water 
' laves the ball. This is repeated a number of times daily. It can readily be 
seen that the stimulation of the circulation due to the reaction may favor- 
ably influence the nutrition of the organ. The eye should be relieved 
of strain by the proper fitting of glasses and such other measures as may 
be indicated. 



DISEASES OF THE CRANIAL NERVES 667 

Paresis of the third nerve produces nystagmus, protrusion and ptosis. 
The external or internal muscles may be alone affected. The causes 
are basilar meningitis, syphilis, neuritis and traumatism. The causal 
malady is to be treated, exudation removed by stimulating absorption, 
followed by full doses of strychnine to arouse the nerves. 

Paralysis of the patheticus is due to similar causes; the eye turns up 
and in. 

The trifacial nerve is more prone to disease and causes more suffer- 
ing than any other. The lesions may be central or peripheral. If the 
lesion is supranuclear the reaction of degeneration is absent; but this is 
rare. 

Internal strabismus from paralysis of the sixth nerve is generally caused 
by neuritis. 

When the center of the facial nerve is diseased we have spasm at 
first, followed by paralysis on the side opposite to the lesion. The nerve 
itself is not degenerated. The corrugator muscle is not affected. Lesions 
of the nucleus are usually bilateral, due to hemorrhage or syphilis, 
Spasm occurs, followed by paralysis and the reaction of degeneration. 
Peripheral lesions may be intracranial, intraosseous or extracranial. 
The paralysis is usually unilateral. The causes are exposure to colds 
and drafts, traumatism, or diseases of the ear. The symptoms develop 
suddenly, the patient waking to find the paralysed side of the face 
motionless; the wrinkles disappear, the mouth draws to the opposite 
side, saliva dribbles, chewing and swallowing are difficult. Anesthesia 
is rare. Taste is unaffected. The duration is from six to twelve weeks, 
depending on the extent of the neuritis and degeneration. Disease of 
the middle ear may attend or exist separately. The sense of taste is 
also affected in such cases, on the anterior two-thirds of the tongue 
on the affected side, from implication of the chorda tympani. If the 
tuning fork is heard better fhrough the ear than over the temporal bone 
the internal ear is affected. If the lesion is intracranial deafness and 
vertigo are present, the former indicating disease of the vestibule, the 
latter of the semicircular canals. Degeneration of the nerve will be 
found after the tenth day. 

The prognosis and treatment depend upon the cause; besides this 
a blister of the mastoid process with quiet, rest, flushing the alimentary 
canal and a mild, unstimulating diet, are of benefit. Absorbents should 
be used early, followed in one or two weeks by full doses of strychnine. 
Galvanism is advised on the tenth day. 

Disease of the auditory nerve causes tinnitus from irritation and deafness 
from destruction. The prognosis and treatment depend on the cause. 



668 NEURITIS 

Disease of the glossopharyngeal nerve causes irritation of the pharynx 
and back of the tongue; destruction causing loss of sensation and taste 
on the posterior third of the tongue. Disease is usually of the centers. 

Disease of the pneumogastric nerve causes many symptoms through- 
out its extensive distribution; from anesthesia of the external ear to 
paralysis of the pharynx, larynx, esophagus, stomach and heart. Neu- 
ritis of its branches explains many thoracic symptoms. 

Irritation of the spinal accessory nerve causes torticollis. This is 
generally due to catching cold, and is most common in children. The 
ear on the affected side is drawn down toward the shoulder. It may 
last for years, paroxysmally, and cause deformity. It is sometimes 
relieved by nervous sedatives, such as gelseminine and cicutine hydro- 
bromide, either of which may be pushed to full effect. Hygienic and 
psychic treatment is usually required. Excision of the nerve or its roots 
sometimes cures and sometimes fails. Contractures require apparatus. 

Disease of the hypoglossal nerve generally causes paralysis of the 
muscles of the tongue. If the disease is central the paralysis is unilat- 
eral. Syphilis is the most common cause. The tongue protrudes 
towards the palsied side. Fibrillary contractions occur, and atrophy 
follows. The treatment depends upon the cause. 

, NEURITIS 

Inflammation of the nerves may be interstitial or parenchymatous, 
as it affects the connective tissue elements or the nerve structures. Acute 
neuritis causes pain and tenderness along the trunk of the nerve, with 
some fever, diminished reflex irritability and increased or diminished 
sensation. The symptoms moderate in a few days, but do not cease. 
The course extends from six weeks indefinitely. The reaction of degenera- 
tion may be manifested after the first week. The causes are various 
toxins developed in or out of the body, infectious or otherwise. The 
diagnosis from myalgia is made by the absence of tenderness on pres- 
sure in the latter, and the distinct limitation of the pain to the affected 
muscles, which may be elicited easily by inducing their contraction with 
a faradic current. From neuralgia the diagnosis is made by the presence 
of local inflammation along the trunk of the nerve; the increase of pain 
on pressure and the presence of fever. The prognosis is doubtful, 
depending upon the cause, the general health and the patient's tract- 
ability. 

Subacute cases last longer, the original infection being slighter. The 
onset is gradual, the symptoms less severe, the prognosis more doubtful. 



NEURITIS 669 

Chronic cases persist more than three months, generally following 
more acute forms. Muscular atrophy is a marked symptom, the local 
inflammation of the nerve trunk being obscure. Paralysis is more 
and the reflexes may be lost, although sometimes they are increased. 
The disease can hardly be confused with rheumatism, which is an inflam- 
matory affection of the joints, shifting from one to the other, while neu- 
ritis is confined to one or more nerve trunks and never shifts, although 
new nerves may be involved. The latter is more common in low, damp, 
ill-ventilated localities. The prognosis is good if the patient submits 
early to intelligent treatment. 

The part involved must be put absolutely at rest, splints or similar 
apparatus being often advisable. Cold or heat may be applied locally, 
or counter irritants applied over the affected nerve. Pain may best be 
controlled by the administration of hyoscyamine, hyoscine, gelseminine 
or cicutine hydrobromide; of either of these a full dose may be injected 
hypodermically as near as possible to the affected nerve. The absorbent 
combination should be employed here (mercury biniodide gr. 3-67, arsenic 
iodide gr. 1-67, iodoform and phytolaccin a a gr. 1-2), as soon as the acuter 
symptoms have subsided under the use of gelseminine. If the pain is very 
acute in the early inflammatory stage moderate doses of aconitine may 
be added to the hypodermic. The practician who is familiar with the 
use of the remedies advised here will not make use of any form of opiate 
in treating neuritis. Absorption may be favored by massage, and the 
resumption of function by affected nerves hastened by the administra- 
tion of strychnine and the use of galvanism. Hygienic measures are 
always necessary, and the diet of the debilitated patient should be made 
as nutritious as his digestion permits. 

Multiple neuritis is generally due to alcohol. Early symptoms are 
toe and wrist-drop, pain along the nerve trunks in the legs and arms, 
loss of the knee-jerk, wasting of the muscles and early reaction of degen- 
eration. The peculiar gait is early manifested, and ataxia may be 
simulated. The digestive disorders of alcoholism attend. Palpitation 
of the heart and disordered rhythm may be present or paralysis of the 
eye-muscles, optic atrophy and blindness. The nails are brittle and 
ridged transversely. Degeneration of the nerve protoplasm occasions 
muscular atrophy. Pain is not so marked as in non-alcoholic forms. 
There is a peculiar mental condition attending these cases, character- 
ized by easy, good-natured acquiescence in anything which is proposed, 
unless it concerns the patient's use of alcohol. The prognosis is good 
if the patient submits to proper treatment. Malaria may cause inter- 
mittent paraplegia. 



670 SCIATIC NEURITIS 

When multiple neuritis is due to lead poisoning, wrist-drop occurs 
early. The onset is rapid and preceded by gastrointestinal disturbances, 
colic, etc., while the blue line on the gums and other evidences of lead 
poisoning may be present. Carbon bisulphide causes neuritis with 
intense frontal headache, excitement, vertigo, muscular cramps and 
sometimes convulsions. 

Multiple neuritis may also be caused by diphtheria. The history 
will clear. up such cases. Arsenical neuritis may be caused by too long 
medication or by sleeping in a room with arsenical wall-paper. The 
head symptoms are absent. 

The treatment depends upon the cause largely. When arsenic, 
lead or alcohol are causative, their use must be stopped and the poison 
in the body eliminated. Besides this, the treatment is to be conducted 
on general principles. The free use of water internally is advisable. It 
must be remembered that the regeneration of the nerve tissue is a slow 
process; but the degree to which this may be effected would only be 
admitted with difficulty by those whose views on disease are exclusively 
founded on post-mortem appearances. 

SCIATIC NEURITIS 

This differs from neuralgia of the sciatic nerve by the evidences of 
local inflammation along the nerve. It is more common in men who 
are exposed to cold and wet, or are very hard workers, hence is found 
in miners, puddlers, stokers, and cabmen. Predisposing causes are 
the neurotic, rheumatic and gouty cachexias, lead-poisoning, diabetes, 
syphilis, typhoid fever, influenza and malaria. It may follow childbirth 
or pelvic operations. It occurs in shoemakers from compression of the 
nerve. It sometimes follows injury of the nerve or excessive fatigue 
of the legs, as induced by continued application to the sewing machine. 
Tumors and other local affections impinging on the nerve give rise to it. 

The symptoms are pain and tenderness along the course of the nerve. 
In inveterate neuralgias this may be altogether induced by pinching 
of the nerve in the sacrosciatic foramen. The suffering may be exces- 
sive and constant, being worse at night, exercise increasing it. Lame- 
ness results, or lateral curvature of the spine. Painful points may 
develop over the trochanter, in the popliteal space, at the head of the 
fibula and the dorsum of the foot; also in the middle of the iliac crest, 
above the sacrum, over the patella, in the calf, behind the ankle or in the 
sole of the foot. Paroxysms of agonizing pain occur at some of these 
points, following exercise or catching cold. Patches of skin may be 



NERVE TUMORS 671 

anesthetic, cramps or tremor of the calf may be present, the knee-jerk 
may be increased or diminished, the heel-jerk absent. Fibrillary 
twitching accompanies atrophy and paralysis. Spasms may be excited 
by the slighest irritation. Vasomotor disturbance may cause flushing 
or lividity, and sometimes edema. The skin is dry or covered with 
sweat. Sometimes erythema, acne, herpes, scaliness or perforating 
ulcer of the foot may be present. Wasting of the muscles is shown by 
the reaction of degeneration. Sometimes the disease is bilateral. 

The diagnosis from neuralgia is made by the evidences of local 
inflammation along the nerve. In myalgia the affected muscle can be 
picked out with the faradic current. In hip-disease there is tender- 
ness in the joint, pain in the obturator nerves and the gluteal crease is 
effaced. Hysteria presents other symptoms of that malady. The diag- 
nosis should always embrace an examination of the rectum and the pelvis 
in the search for causal lesions. The prognosis is good if uncompli- 
cated; otherwise it depends upon the cause. The course will be shorter 
if the patient can be confined to his bed. Atrophied muscles require 
considerable time for reconstruction. 

The treatment is that of local neuritis. Special points are the exam- 
ination for rectal diseases and for pinching at the sacrosciatic foramen, 
whose enlargement in such cases we commend to the attention of the 
surgeon. Nerve stretching sometimes relieves the nerve of adhesions 
and proves beneficial. Massage with hot camphor liniment along the 
affected nerve is useful. 

NERVE TUMORS 

Hypertrophy of the nerve trunks is rare; hyperplasia of the connec- 
tive tissue somewhat more common. Neuromata are rarely found on 
the spinal nerves. They are usually quite small and few in number. 
More common are neuromata mixed with fibroma, myxoma, glioma, 
sarcoma, carcinoma and syphiloma. The causes are hereditary, dieteti 
or traumatic. There may be no symptoms, the most frequent being 
pain and tenderness, paresthesia, anesthesia, paralysis and reflex spasm. 
The diagnosis is made by physical examination. The treatment is 
surgical. 

Any single nerve may be subject to disease or injury giving rise to 
new growths, division, degeneration or neuritis. Irritative symptoms 
are hyperesthesia, pain, spasm, tremor, contraction and hypertrophy. 
Destruction causes anesthesia, paralysis, dystrophy and atrophy. The 
symptoms differ as the nerve affected is sensory, motor or mixed. 



672 NERVE AFFECTIONS 

Disease of the phrenic nerve causes intercostal pain, paralysis of 
the diaphragm with costal breathing, and extreme dyspnea. 

The suprascapular nerve may be injured in shoulder dislocation, 
the spinatus groups wasting, with weakness and disability of the arm. 

The long thoracic nerve is frequently injured by pressure, the chest 
expansion being affected and movement of the arm hindered. Paral- 
ysis of the serratus causes the scapulae to project, wing-like. Affections 
of the circumflex nerve cause paralysis of the deltoid muscle with wast- 
ing and anchylosis. Paralysis of the intrascapular nerve causes wast- 
ing of the spinatus groups. When the musculospiral nerve is affected 
the extensors and supinators of the forearm are paralyzed. Affections 
of the ulnar nerve are shown in the flexors of the forearm and the small 
muscles of the hand, excepting those supplied by the median nerve, the 
radial flexors and the pronators. Frequently two or more of these nerves 
are affected simultanously. 

In neuritis of the brachial plexus we have pain and tenderness in 
the distribution of the affected branches, increased on motion of the 
shoulder. It is more common in women, after middle life, especially 
the gouty or rheumatic. The muscles are tender and waste, giving the 
reaction of degeneration. Reflexes are generally weakened. Perma- 
nent cure is unusual. 

The most common affection of the nerves of the trunk is herpes 
zoster. 

The nerves of the legs are less frequently affected than those of the 
arms with the exception of the sciatic. The external cutaneous branch 
of the anterior crural nerve is sometimes affected. The patient com- 
plains of burning frequently in the outer upper part of the thigh. This 
occurs in neurasthenic women with ovarian disease. When ■ the anterior 
crural nerve is affected the knee-jerk is abolished, the quadriceps wastes 
and the skin is anesthetic from the drawing of the foot. Paralysis of 
the obturator nerve inhibits the abductors of the thigh, while affections 
of the superior gluteal nerve are shown in irritation or paralysis of the 
gluteal group. Paralysis of the calf muscles indicates an affection of 
the internal popliteal nerve. 

Morton's metatarsalgia is due to neuritis caused by pressure of the 
heads of the metatarsal bones. Narrow shoes may account for it. 
There is sudden agonizing pain opposite the fourth toe and shooting 
up the leg. It may be relieved by firm pressure, as by a well-fitted shoe. 

Rhizomelique spondylitis is an inflammatory affection of the spine, 
probably of nervous origin. It may cause almost as much deformity 
as humpback, although not angulated. The causes are conjectural; 



ACUTE ASCENDING PARALYSIS 673 

heredity, cold, wet, traumatism and gonorrhea have been suggested. 
The symptoms are pain, increased by sleeping, limited motion, girdle 
pains, sometimes paraplegia with areas of hyperesthesia or anesthesia. 
Motion may induce severe pain. The vertebral cartilages are absorbed. 
Muscular spasm contributes to the deformity. The prognosis is bad, 
although sometimes treatment stops the progress of the disease. As 
in the vast majority of nervous diseases, it is dawning upon the medical 
profession that fecal autotoxemia is a potent factor in the causation, 
and the removal of this as a possibility is one of the cardinal elements 
in their treatment. 

ACUTE ASCENDING PARALYSIS 

LANDRY'S PARALYSIS. 

An acute disease characterized by an ascending paralysis, beginning 
in the legs and extending upwards, involving the muscles of the upper 
limbs and trunk, often affecting the muscles of the face, tongue, palate, 
larynx or eyeballs. The disease is of short duration, death usually 
resulting from respiratory paralysis. 

But little is positively known regarding the pathology. By some 
observers the disease is believed to be really an acute myelitis or an 
acute polyneuritis. The prodromal stage suggests an acute infectious 
disease, inasmuch as there is fever, splenic and lymphatic enlargement, 
and occasionally albuminuria. Softening and extravation of blood into 
the gray substance have been observed. 

It is not known what is the chief cause of the disease. It has 
followed influenza, the infectious fevers, traumatism and exposure to 
cold. It occurs most frequently in males and between the ages of 
twenty and fifty years. Alcohol and syphilis do not seem to be exciting 
factors. Pearce attributes it to autotoxemia. 

The period of • invasion is usually quite abrupt. More frequently 
the prodromal symptoms exist but a few hours, although in some cases 
premonitory symptoms have been noticed for several days or even weeks. 
These symptoms are usually sensory in character and consist of tingling, 
formication, numbness and dull aching or shooting pains. There also 
may be gastralgia or diarrhea. The patient is restless and fidgety, with 
stiffness of muscles, chilly sensations, some elevation of temperature, a 
feeling of heaviness and languor, malaise and loss of appetite. Some- 
times the extremities are cold with clammy sweating of the soles and 
palms. The spleen is always enlarged. In the period of paralysis the 
sensory symptoms may persist, although in the majority of cases they 



674 ACUTE ASCENDING PARALYSIS. 

are not pronounced. Marked anesthesia has been observed in some 
cases, painful impressions being more impaired than tactile. There 
is marked weakness followed by paralysis of the lower extremities, one 
leg being affected a few hours before the other. The paralysis quickly 
ascends, involving first the muscles of the trunk, principally those of the 
abdomen and back, then the arms. In almost all cases the paralysis 
is flaccid, there being no muscular resistance when the extremities are 
passively moved. Usually, but not always, the electrical excitability 
remains normal. The reflexes disappear. The bladder and rectum 
are not affected in the majority of cases, neither do bed-sores develop. 
There are no cerebral symptoms. Death usually results from bulbar 
involvement resulting in cardiac or respiratory failure or inability to 
swallow. Very rarely the disease shows a descending instead of an 
ascending course. 

Death may take place in from two or three weeks to several days. 
There have been a few cases of recovery reported. The improvement, 
if any, takes place in the reverse order to the onset, the part last affected 
being the first to show signs of recovery, but the improvement is much 
slower than the invasion. 

Diagnosis: — The acuteness of the attack, the ascending paralysis, 
the prodromal symptoms, the absence of electrical excitability and the 
slight sensory symptoms usually enable one to easily make a diagnosis. 

Acute myelitis is more often mistaken for Landry's disease, but in 
this disease the paralysis does not begin in the lower extremities and 
extend to the trunk and upper limbs but is sudden and complete. Bed- 
sores are common and wasting is marked, while there are no trophic 
changes in acute ascending paralysis. Moreover there are e arly 
involvement of the sphincters, reaction of degeneration and sometimes 
girdle pains, which are never present in Landry's disease. 

Prognosis is always unfavorable, and more so if bulbar symptoms 
occur. 

Treatment: — But little can be done. Massage, baths and electricity 
are of value, especially to hasten convalescence when the symptoms 
have been arrested. Absolute rest and entire freedom from worry and 
excitement are essential. Free elimination by the bowels, skin and 
kidneys, and respiratory and cardiac stimulants are indicated. Digitalin, 
strychnine, atropine, ergot and the iodides have been recommended. 

The writer has had two cases in women in which the malady was 
attributed to residence in the elevated regions of the Rocky mountains. 
One case was not improved by removal to Chicago; in the other the prog- 
ress of the disease was arrested. Intestinal antiseptics were here employed. 



LEPTOMENINGITIS. 675 

II. DISEASES OF THE SPINAL CORD 
AND MEMBRANES 

EXTERNAL PACHYMENINGITIS 

External pachymeningitis may occur acutely with caries, tumors, 
aneurisms or syphilis. Abscesses may penetrate to the cord or inflam- 
mation occur in persons long confined to their bed. The symptoms 
are those of myelitis from compression. The chronic form is usually 
caused by vertebral tuberculosis. The internal surface of the dura is 
smooth, the external roughened by cheesy deposits. 

Internal pachymeningitis is generally found in the neck. The space 
between the cord and dura is filled with interlacing fibers, the cord 
compressed, the central canal dilated and the nerve substance degen- 
erated. The nerve roots are involved. The first period is painful, the 
second paralytic, the third spastic. The symptoms are intense pain 
along the nerve whose roots are involved, with hyper- or anesthesia and 
atrophy of the muscles of the hand. The arms are weak, especially 
the flexors, so that the emaciated hand becomes claw-like. The lower 
limbs may be involved some months later, with spastic paralysis from 
secondary degeneration. The bladder may then be paralyzed and 
bed-sores form. The disease lasts two years or more. Recovery some- 
times takes place. 

The diagnosis is made by the presence of the symptoms stated, with 
the history of the causal malady. The prognosis is doubtful. The 
most acute cases end fatally, and recovery may be imperfect and fol- 
lowed by relapse. 

LEPTOMENINGITIS 

This condition is closely allied to the preceding. Clinically we find 
the two usually together. This, however, is likely to be very diffuse, 
it being generally due to sepsis. Serious symptoms, therefore, follow 
slight inflammation. The" attack is fulminating, with less pain but 
more paralysis. It is generally acute. The back is fixed, head retracted, 
spine tender, muscular tremor and spasm present, followed by palsy 
The prognosis is uncertain, depending upon the virulence of the infec- 
tion and the extent of the disease. Diagnosis may be aided by lumbar 
puncture. Marked paraplegia occurring early is unfavorable. The 
hypertrophic form is sometimes caused by the gonococcus. 



676 SPINA BIFIDA 

The treatment consists in absolute rest in bed, in a quiet dark room 
with ice to the spine if the symptoms are acute; if not, silver nitrate should 
be applied. The actual cautery is even more promptly efficacious. 
Fever should be met by veratrine, and the absorbent remedies brought 
promptly and decisively into operation at an early date. Inunctions 
of colloid silver have been employed with benefit. Persistent convul- 
sions call for solanine, with special care directed to the eliminants. 
Massage and systematic movements are of value later. 

CAISSON DISEASE 

Exposure for long periods in compartments containing compressed 
air gives rise to this affection if the pressure exceeds three atmospheres. 
The symptoms are paraplegia and sometimes general paresis, developing 
when the individual suddenly returns to the ordinary atmospheric 
pressure, immediately or several hours afterwards. Pains are felt in 
the knees, sometimes quite severe, also in the abdomen, with vomiting. 
The muscles are tender, the gait spastic, with dizziness, intense headache, 
in severer forms complete motor and sensory paraplegia. Extreme 
attacks resemble apoplexy, with profound coma and death within a few 
hours. In ordinary cases the paralysis may subside in a day or con- 
tinue for months. The disease is thought due to vasomotor disturbance. 
Hemorrhages have been found in the substance of the spinal cord. 
The patient should be kept quiet, pain controlled by the usual remedies, 
and the paralysis treated like that due to any other cause. The disease 
does not appear if the workman spends at least five minutes in com- 
partments each an atmosphere higher than the preceding. The same 
precaution should be taken when coming out. Ergot has been advised 
to control the vasomotor nerves, given in full doses. 

SPINA BIFIDA 

Imperfection in the development of the vertebrae permits a hernia 
of the spinal membranes. In France one child in 1200 is thus affected. 
Other developmental defects may attend. Heredity may have some 
influence. It is more common in boys. The spinal membranes alone 
may protrude, or the cord as well, while in syringomyelocele the fluid 
occupies the central spinal canal. The latter is a rare form. The walls 
of the protrusion are lired with the dura and arachnoid. If the nerves 
and cord protrude they form part of the posterior and median walls. 
Fat and connective tissue are also present in the tumor. The protru- 



PRIMARY LATERAL SCLEROSIS 677 

sion is usually in the lumbar and sacral regions, involving two or more 
vertebrae. The skin over it may be glossy, tough, thick or ulcerated. 
The children are poorly nourished, feeble, with weak mentality. Para- 
plegia attends one-half the cases, sometimes with anesthesia and 
sphincter involvement. Contractures also occur. The prognosis is 
grave, these patients being very liable to injury, infection and secondary 
myelitis. The diagnosis is unmistakable. If the cord and nerves are 
protruded, the paretic symptoms are marked and there is a depression 
marking the nerves' attachment. The most successful treatment as 
yet devised is the injection of Morton's fluid, which consists of iodine 
gr. 10, potassium iodide gr. 30, glycerin 1 ounce; one dram of this is 
injected on the outer portion of the sac, the child being kept on its back. 
The operation should not be done until the child is four months old. 

PRIMARY LATERAL SCLEROSIS 

In this disease muscular paralysis begins in the legs, with increased 
reflexes but without atrophy or sensory disturbance. It is most frequent 
between twenty and forty years. Alcoholism and syphilis, hereditary 
or acquired, traumatism, exposure to cold and wet, infectious maladies 
and excesses inducing debility, especially of the nervous system, are 
considered the causes. The first symptom is rigidity, with weakness 
of the leg muscles, dull pains or a sense of fatigue. One leg may be 
affected sooner or worse than the other. The weakness is gradual and 
not in proportion to the difficulty in walking, which is here due to 
rigidity. This lessens if motion is persistent. The leg extensors may 
contract with spasmodic rapidity; the adductors also become spastic — 
cross-leg gait. The patient trips over slight objects or wears out the toes 
of his shoes. The feet are raised with difficulty and soon are simply 
pushed over the floor. Voluntary effort increases the spasm of the 
muscles. The knees are kept close together and the feet may cross in 
walking. The deep reflexes are increased, the superficial ones slightly. 
The muscles feel firm and . are only wasted through disuse. The 
sphincters are only involved quite late. Paresthesia may be present. 
The arms are only involved late. Trophic ulcers are rare, but the 
affected members are readily frost-bitten. 

The disease may last many years. It consists in a degeneration of 
the pyramids; whether primary or secondary is uncertain. From 
transvere myelitis it is distinguished by the absence of sensory symp- 
toms; the chronic course and the late affection of the sphincter. In 
ataxia the muscles are less spastic, the sphincters are involved and 



678 FRIEDREICH'S ATAXIA. 

incoordination is marked. In amyotrophic lateral sclerosis there is 
muscular atrophy. The prognosis is steadily progressive to the 
bad although death may not be hastened. The older treatment is not 
encouraging, silver, gold and iodine having been administered without 
any distinct indication or special results. 

SPASTIC PARAPLEGIA 

This may be due to chronic myelitis and also accompanies a congen- 
ital lateral sclerosis. It may be hereditary . The symptoms appear 
soon after birth or in hereditary cases up to maturity. It may be con- 
fined to the legs. It is distinguished from cerebral paralysis by the lack 
of mental involvement. Sometimes the limbs cross in walking. The 
arms are less affected; the muscles of the face and neck may be slightly 
involved. There is no pain. Sometimes the progress is quite rapid un- 
til the patient becomes helpless from contractures; epilepsy or mental 
degeneration may develop at puberty. Mild cases may improve under 
treatment but severe ones rarely reach youth. The treatment consists 
in massage and systematic training of the affected muscles with the treat- 
ment recommended in general for nerve degeneration. 

FRIEDREICH'S ATAXIA 

This occurs in early youth, generally in males, the patient having 
previously been in good health but susceptible to nervous maladies. It 
may be hereditary although never congenital, syphilis and alcohol being 
the progenitors. The symptoms consist in ataxia, with choreic motions, 
sometimes athetosis, the speech punctate and drawling, with dribbling 
of saliva, difficulty in mastication and swallowing. The mind is better 
than is at first apparent. The Argyll-Robertson pupil is not constant, 
but nystagmus is common, generally bilateral. Romberg's symptom 
is common. The knee-jerks are usually absent, changing from year to 
year. Sensory symptoms are absent. The sphincters are not affected. 
Club-foot may occur and local muscular atrophies with fibrillary Switch- 
ings. The spine may curve from the loss of muscular support. 

The disease consists in a hyperplasia of the connective tissue, espe- 
cially in the posterior roots and columns of the cord, with round-cell in- 
filtration in other parts and isolated areas. The patient usually dies 
before reaching maturity. The treatment is symptomatic and pal- 
liative. 

Cerebellar ataxia is also hereditary, becoming manifest at or after 
the fifteenth year. In it we have ataxia, the cerebellar gait, the knee- 



SPINAL MALADIES 679 

jerks variously altered, rarely ankle-clonus. It may endure for ten years, 
contractions causing club-foot. The lesion is a degeneration of Purkinje's 
cells in the cerebellum and posterior columns of the cord. Optic atrophy 
and nystagmus may be present. 

SPINAL MALADIES 

Acute hyperemia may be caused by violent exertion, sexual excess, 
amenorrhea, and by some poisons such as strychnine. The chronic 
form rarely follows meningitis or injury. The symptoms are a sense of 
weight around the loins, twitching muscles, formication, neuralgic pain 
and anesthesia of the legs. The sphincters may be involved. The 
affection is of problematic existence. It could only be recognized dur- 
ing life, and opportunities for such observation of the cord under normal 
conditions are obviously rare; while it must be exceedingly difficult for 
the circulation of the cord and membranes to be disturbed. If the 
disease is recognized the treatment consists in the application of cold 
or counterirritation over the spine, with sedatives such as gelseminine, 
cicutine, and especially solanine internally. 

Even less is known of spinal anemia, but it may be caused by a 
severe hemorrhage or diarrhea, or by any local obstruction to the supply 
of blood. Serious disturbance of the cord may result from disease of 
its arteries, or sclerosis may follow pernicious anemia. The descriptions 
in the older books of practice are imaginary. 

Spinal hemorrhage is more common in men and in new-born infants, 
the cause being traumatisms or the convulsions of epilepsy, tetanus, 
chorea, eclampsia and strychnine. It may occur in purpura and simi- 
lar affections, or from the rupture of an aneurism. Very small hemor- 
rhages may cause no symptoms. In large ones there is severe pain in 
the back, shooting down the limbs, with numbness and hyperesthesia, 
spasm of the back and other muscles, followed by paralysis and abdomi- 
nal disorders. The acme is reached in a few hours, when death may 
occur from exhaustion, or slow recovery, or chronic inflammation. The 
diagnosis is made by the above symptoms and the history. If the 
patient survives the fifth day he has a chance for recovery. Enjoin 
absolute rest in bed, empty the bowels and keep them clear, apply 
leeches or cups over the lesion and keep the patient comfortable with 
sedatives. In a few days the absorbents may be employed, with silver ni- 
trate over the affected portion of the spine. 

Hemorrhage sometimes occurs in the substance of the spinal cord, 
from purpura or similar diseases, in myelitis, or in consequence of 



68o SYRINGOMYELIA 

tumors. It may occur primarily in infancy or in young men, from trau- 
matisms, convulsions, exposure, overexertion, syphilis or sexual excess. 
n In the aged it sometimes occurs with arteriosclerosis, forming a true spinal 
apoplexy. The symptoms follow the effusion rapidly, as numbness 
or weakness, followed in a few hours by sudden paraplegia or ataxia, 
or both. The senses of pain, heat and cold may be lost, while 
that of touch is retained. Retention of urine is usual. The reflexes 
may disappear, returning in exaggerated form. Pain in the back is 
severe. If the lesion is high enough up, the anus or even the thorax 
may be involved. Within two weeks the symptoms subside into those 
of chronic myelitis, or death will occur from acute inflammation. The 
vessels are first degenerated. Rupture is most frequent in the central 
cord. The hemorrhage is generally single but not always. The diag- 
nosis is made by the sudden onset, without premonition, and the absence 
of fever. The pain is less than in meningeal hemorrhage. The dis- 
sociation of sensation is characteristic. The prognosis is good as to life, 
doubtful as to recovery, depending on the extent and seat of the hemor- 
rhage. The treatment is cold to the spine, emptying the bowels by 
exosmotic enemas, and the use of cardiac depressants like aconitine. 
Beyond this it is strictly symptomatic. 

SYRINGOMYELIA , 

Dilatation of the spinal cord may occur in two forms-^— hydromyelia, 
dilatation of the central canal, or as a cavity in the gray matter from 
softening of a glioma. The latter is hereditary. There may be one 
or many cavities, separate or connected, in one or both halves of the 
cord. The most common site is the cervicodorsal part. The malady 
may follow acute infections which arouse the hereditary tendency. 

As various areas of the cord are affected by the disease the symp- 
toms resemble those of ataxia, lateral sclerosis, spinal muscular atrophy, 
etc. In cases of irregular atypic spinal cord disease syringomyelia is 
always a possibility, especially if there is a hereditary tendency to it. 
The special characteristic is dissociation of the sensory phenomena, 
such as loss of pain and temperature sense in irregular areas, with reten- 
tion of tactile and muscle sense. When one side is affected we may 
have Brown-Sequard paralysis, with the above described dissociation, 
or anesthesia, or absence of all sensations. If the affection is high 
enough up the cord to involve the fifth nerve's ascending branch the 
face will be anesthetic. Involvement of the cervical sympathetic causes 
contraction of the pupil on the affected side, sometimes with absence 



ACUTE ANTERIOR POLIOMYELITIS 68 1 

of sweating. If the centers controlling the spinal muscles are destroyed 
we will have lordosis or scoliosis. The motor cells may be affected, 
with muscular atrophy and curvatures of the spine. The reflexes are 
destroyed as the disease penetrates more deeply. Atrophy of the legs 
may ensue, and the reaction of degeneration be elicited from the affected 
muscles. The course of the disease is slow and it may pause for a time. 
Death may be due to extension to the centers of the heart and lungs. 
No special treament has been evolved. 

ACUTE ANTERIOR POLIOMYELITIS 

This malady attacks children, and is probably of microbic causa- 
tion. The attack is sudden, with a chill followed by fever of 104 or 
more, nausea, vomiting restlessness and hyperesthesia of the extrem- 
ities. The fever abates within two days, leaving the child weak and 
with paralysis of one or more limbs, which waste rapidly and afford the 
reaction of degeneration during the second week. The anterior tibial 
group is more frequently affected, next coming the calf, femoral exten- 
sors and adductors. The arms are not often affected alone. The deep 
reflexes are abolished, the limb cold, clammy, cyanosed and wasted. 
Contractures and other deformities follow. Extension is unusual. The 
affected member does not grow with the rest of the body. The sphinc- 
ters are nevei involved, nor is decubitus often present. The paralysis 
at first rapidly improves and then promptly develops. The malady 
may be epidemic in spring and summer. 

It is an acute inflammation of the multipolar cells in the anterior 
gray horns, especially in the dorsolumbar region. These cells degener- 
ate, the connective is hyperplastic, and the nerves springing from the 
affected section participate in the degeneration. 

The malady is more sudden in onset than neuritis, the. paralysis 
more decided, with no tenderness of the nerve trunks. Diagnosis is 
to be made from hip-joint disease, rickets, muscular dystrophies and 
cerebral paralyses. 

As an acute infection, the treatment should be that of such maladies 
— cleaning out the bowel, disinfecting it, subduing fever, and promptly 
saturating with the sulphides, reinforcing the leucocytes, etc. When 
the fever subsides the debris is to be promptly removed by absorption 
stimulation, and the nutrition, general and local, at once enhanced. As 
wasting is so prominent the local use of hot cod-liver oil inunctions is 
advisable. The nutrition of the affected tissues may be enhanced by 
the use of neuro-lecithin. 



682 BULBAR OR GLOSSO-LABIO-PHARYNGEAL PARALYSIS 

Systematic exercises may aid in developing the affected limb. 
Pearce advises placing the child in a warm bath and there exer- 
cising, as the water sustains the limb and allows less fatigue from 
movement. 

BULBAR OR GLOSSO-LABIO-PHARYNGEAL PARALYSIS 

The symptoms are due to disease affecting the medullary centers 
of the 5th, 7th, 9th, 10th, nth,, and 12th cranial nerves. Other "ner- 
vous maladies may also be present. In the acute form we see a sudden 
onset, dribbling of saliva, motor difficulty of speech and atrophy of the 
tongue. The attack may resemble apoplexy. The malady ' progresses 
rapidly, swallowing grows difficult, wasting ensues, choking occurs with 
solids or even with liquids, the speech is drawling, consonant pronuncia- 
tion being first affected. The mental faculties are unaffected. Writing 
is perfect. 

The course is rapid, and in a few months death occurs from pneu- 
monia, choking, or involvement of the vagus centers. In all forms the 
symptoms are bilateral, the tongue first affected. . 

The chronic type presents similar symptoms but they are developed 
slowly, and the general health does not suffer so much. While the 
acute form is based on inflammation, softening or minute hemorrhages 
in the bulb, with bilateral symptoms, in the chronic there is atrophy of 
the motor neurons, and one side is more involved. This may last up 
to 18 months, or several years, with irregular heart-action and attacks 
of tachycardia. The disease is progressive and no treatment has as yet 
succeeded in more than apparently delaying it. The stomach tube may 
be required to feed the patient. Strychnine in full doses has proved 
beneficial, and possibly among the other members of the strychnine 
group may be found more effective remedies. Galvanism of the affected 
muscles is useful. 

The asthenic form occurs later in life, about the 40th year, more in 
women than men. Pearce attributes it to an autointoxication, from 
defective metabolism. The motor cranial nerves are affected, the cen- 
tral impulses wanting. The above described symptoms are presented, 
with remissions recurring regularly. The course is more prolonged. 
Possibly the prevention of toxemia may give better results — the fact 
of a remission does not allow the hypothesis of a destructive lesion. 

In pseudobulbar paralysis we have a progressive failure of these 
muscles without atrophy or general weakness. It is attributed to cere- 
bral lesions. 



MYELITIS 683 

COMBINED SCLEROSES 

Many variations have been described, as various portions of the cord 
are involved simultaneously. The Putnam-Lichthein-Dana type occurs 
in elderly persons, with some cachexia, such as pernicious anemia, 
malaria, lead poisoning, chronic diarrhea or influenza. Heredity may 
also often be established. The first symptoms are persistent pares- 
thesia, slight weakness, especially of the feet, followed by ataxia. There 
may be pain in the limbs and back. At first there is spasticity of 
muscles, increased knee-jerks and ankle clonus, rigidity subsiding later 
and both reflexes lost. Romberg's symptom is usually present. The 
arms are similarly affected some months later. Sometimes the malady 
commences in them. The tactile senses may be weakened or disso- 
ciated. Dementia may develop. The malady attacks the posterior 
columns first and most severely. The lateral columns are generally 
affected also, the anterior later. The cord may soften and cavities form. 

Diagnosis is to be made from ataxia, posterior lateral sclerosis, 
syringomyelia, etc. The patients survive from six months to some years, 
and some improve greatly. There is no special treatment. 

MYELITIS 

Inflammation of the spinal cord commences insidiously, sometimes 
abruptly. The course may be mild, severe or fulminant. The causes 
are exposure to cold and wet, traumatism or sepsis. It is most com- 
mon in men. A low inflammation with round-cell infiltration, more in 
the gray matter, resulting in granular debris and fatty degeneration of 
the cells with connective hyperplasia. Myelitis may be transverse, 
ascending or descending. 

The onset is sudden, with a little fever, paresthesia and weakness 
of the legs, rapidly increasing until the patient is confined to bed, with 
incontinence of urine and feces. The arms are involved only if the 
malady extends above its usual seat in the lumbar cord. The reflexes 
are first increased and ankle clonus may develop, the gait spastic and 
becoming ataxic, as the posterior white columns become involved. 
Atrophy of the muscles follows involvement of the multipolar cells. 
In acute cases the irritative symptoms will soon give place to anesthesia 
of both legs, or up to the navel. Retention of urine and cystitis then 
appear. Bedsores form, the reflexes are abolished, wasting occurs, 
with hectic or septicemia which may be fatal. Or, partial recovery may 
follow after a long course, or as in traumatic cases, the cord remain 



684 MULTIPLE SCLEROSIS 

permanently impaired. When almost complete recovery follows an 
acute attack the meninges have probably been the seat of the malady. 
The legs are cold, clammy, cyanosed and low in vitality. 

The diagnosis is from neuritis, subacute rheumatism and spinal 
syphilis. Prognosis should be guarded. 

The treatment consists in absolute rest in bed, the defer vescent 
alkaloids for fever, precautions against bedsores, analgesic alkaloids 
for pain, attention to the bladder to prevent retention, and the early 
vigorous use of absorbents. The muscles should be exercised by fara- 
dism and massage to prevent wasting. Too early activity is perilous. 

MULTIPLE SCLEROSIS 

We find in this chronic malady small areas of sclerosis disseminated 
through the brain and spinal cord, one or both, especially in the white 
matter. The causes assigned are injury of the spine, exposure to cold 
and wet, with toxemia, overwork, emotion, perverted secretions and 
excretions, infectious diseases and metallic poisons. This is purely 
conjectural — the etiology has never been absolutely demonstrated. 

The symptom picture varies with the location of the lesions. The 
limbs are weak, becoming spastic, the deep reflexes exaggerated, coarse 
tremors develop in the affected parts, of the intention type, awaked or 
exaggerated by volition, invading arms, legs and later the head. Tremor 
subsides when the part is at rest, certainly during sleep. It may be so 
coarse as to resemble ataxia. Nystagmus is common, persistent, usually 
lateral, possibly developed only by strain. Paralysis of ocular muscles, 
optic atrophy and sometimes Argyll-Robertson pupil occur. The lower 
cranial nerves may be involved. The speech may be slow, scanning, 
resembling that of bulbar palsy or Friedreich's ataxia, or of paretic de- 
mentia. Vertigo and seizures like apoplexy or epilepsy may occur, or 
anesthesia in patches or of half the body be found. Paresthesia is com- 
mon. The diagnosis is easy. The course may be interrupted by re- 
missions. Cerebrospinal syphilis does not often show intention tremor, 
nystagmus and scanning, and the pupils are affected frequently. Tre- 
mor of paralysis agitans occurs when at rest and may be stopped at will. 
Parkinson's disease occurs in the aged and has no nystagmus or scanning. 
Infantile cerebral palsies appear earlier, with convulsions and arrest of 
mental development. Scanning, nystagmus and ataxic movements may 
be present in the diplegic form but not all three in the same case, while 
marked paralysis and contractures occur. In Friedreich's ataxia we see 
~* heredity, optic atrophy, reflexes diminished, and leg ataxia; in cerebellar 



LOCOMOTOR ATAXIA 685 

forms Romberg's sign. The malady is slow but incurable. The re- 
missions have not been shown to be due to treatment or not due to it. 
No special treatment has been established. 

LOCOMOTOR ATAXIA 

This is a disease of the posterior columns of the spinal cord, character- 
ized by progressive changes, incoordination, sharp lancinating pains, 
absence of patellar reflex, and the Argyll-Robertson pupil. 

Pathology: — The cord is smaller and thinner, the posterior roots smaller 
and pia mater thickened, adherent, opaque or slightly congested. The 
degeneration of the posterior and middle portions of the posterior columns 
is more pronounced in the lower lumbar and dorsal regions, primarily 
in the tract of Lissauer. The sclerosis extends as the disease progresses 
so that in advanced cases the fasciculus of Gall is involved. There are 
changes in the peripheral sensory, sometimes in other sensory nerves, 
the cerebrum, optic nerves and cerebellum. Occasionally atrophy and 
absorption of the articular surfaces of the bones is found. 

Etiology: — The disease is more common to the white races, not often 
seen among the colored races, even less frequently among Jews. Males 
are more liable, most frequently in middle life. 

Many believe that syphilis is the chief cause. It is claimed that the 
history of syphilis is found in 90 per cent of the cases; but syphilis is 
extremely common, and, is more often found among races least suscep- 
tible to ataxia. 

Tabes is not pathologically identical with syphilis, it is not pathologic- 
ally a gummatous disease of the cord and brain, such as could be re- 
moved by antisyphilitic treatment; indeed, such treatment has but little 
if any value in this disease. 

In all probability syphilis is a predisposing factor, acting, possibly, 
similarly to that of the elaborated toxin of diphtheria, or certain drugs 
having a selective action on certain cells and tissues. Such drugs as er- 
got or lathyrus have a selective action on certain portions of the spinal 
cord, the symptoms of chronic ergotism often being precisely like those 
of tabes; the cord also undergoes a degeneration analogous to that of 
tabes Syphilis has no selective action on any particular part. The 
disease may, however, and probably does lay the foundation in many 
cases for locomotor ataxia, by either a specific toxemia affecting the cord, 
or by so lowering the vitality of the patient that the cells of a certain por- 
tion of the spinal cord undergo degeneration because of their pecul'ar 
susceptibility to sclerosis in certain individuals. 



686 LOCOMOTOR ATAXIA 

Heredity may have some influence; various nervous diseases are 
often found in the family history of the patient. Autotoxemia, and the 
toxemias resulting from infectious diseases, may produce the disease. 
Autotoxemia is a much more frequent cause of the various scleroses than 
is generally believed (G. F. Butler). Other determining causes are ex- 
posure to cold, over-exertion especially when combined with exposure 
and privation; traumatism, especially an injury to the spine such as a 
shock, blow, or fall; alcoholism, and sexual excess. It is doubtful if 
alcoholism and sexual excess are often, or even rarely the cause of tabes. 
So far as the latter factor is concerned it must be remembered that ab- 
normal sexual excitement with excessive indulgence are among the early 
symptoms of the disease. 

Symptoms: — The disease may be divided into several stages — usually 
three, although the clinical course is extremely varied in intensity, dura- 
tion and order of the occurrence of symptoms. 

In the first or preataxic stage the patient complains of pains usually 
in the legs. At first they are very slight and may not increase in frequency 
or intensity for some years, but after a while the pains occur more often 
and are more severe, increasing as the disease progresses, and described 
as " lightning pains" — sharp, shooting, stabbing or boring, sudden in 
onset and of momentary duration. They may be paroxysmal and peri- 
odic, with longer or shorter intervals of ease, and are generally aggravated 
by damp or cold winds. 

While the early pains are usually confined to the legs, they occasion- 
ally begin in the face or head. Like neuralgia, again, the pains are some- 
times succeeded by a temporary cutaneous hyperesthesia. 

The pupils do not contract to light suddenly thrown upon the eye, 
but contract normally when the patient attempts to fix a near object. This 
phenomenon is known as reflex iridoplegia, or as the " Argyll-Robertson 
pupil." Occasionally, and rarely, there are variations of this phenomenon; 
thus the pupil may contract to light and then dilate though the illumina- 
tion be still present. Then again, the pupils may neither react to light 
nor to accommodation. The pupils are commonly contracted even to 
"pin point," and symmetrical in size and action, though inequality in 
the size of the pupils is not infrequently found. Unilocular iridoplegia, 
however, is very rare. 

There may be slight incoordination of movement noticed, if at all, 
at night or in the dark, though ataxia does not usually appear until later 
in the disease. There is diminution or absence of the patellar reflexes 
(Westphal's sign). The knee-jerk in the early stages is occasionally 
exaggerated, but as a rule it is gone when the patient first comes under 



LOCOMOTOR ATAXIA 687 

the physician's observation. In this stage the patient sometimes com- 
plains of severe concentrated pain in the stomach, accompanied often 
by vomiting — " gastric crises". There is difficulty of micturition and 
markedly increased or impaired sexual power. 

The second or ataxic stage is characterized by incoordination of move- 
ment giving rise to the ataxic gait. It begins by an unsteadiness in walk- 
ing, more noticeable when the patient rises to walk, or when he turns 
suddenly, or when he is made to hop backward on one leg, walk back- 
wards, or walk a given line, and when he attempts to walk up and down 
stairs. As the ataxia increases the legs are kept far apart, the feet lifted 
unnecessarily high from the ground and brought down with a stamping 
motion. The feet often get crossed in attempting to turn around. The 
patient bends forward at the hips and looks at his feet. He is unable to 
rise from his seat quickly and often requires assistance to start. Even 
when sitting he cannot thoroughly control the movements of his legs, 
which can be demonstrated by his attempt to touch one knee with the 
opposite heel or describe a circle with his toe. The patient will sway 
and stagger if he attempts to stand erect with his feet together and his 
eyes closed (Romberg's symptom). The incoordination gradually ex- 
tends to the upper extremities so that he is unable to rapidly touch the 
tip of the nose with the forefinger, or to spread his arms apart and bring 
the forefingers rapidly together. He has difficulty in buttoning his clothes, 
in writing, or in picking up small objects. This maldirection of move- 
ment is increased when the patient's eyes are closed. 

The reflexes are now completely abolished. The muscles begin to 
atrophy in many cases and there is more difficulty in urination, often as- 
sociated with incontinence. By this time there are various disturbances 
of sensation. Gastric crises, already referred to, are common now. Other 
crises involving the larynx, liver, kidneys, urethra, clitoris, or intestines, 
may occur. Laryngeal crises are characterized by paroxysmal cough 
and dyspnea, and may be accompanied by coma or convulsions. 

Hyperesthesia, analgesia and paresthesia are present. There is often 
complete loss of sensation in the testicles and breasts, and in the ulnar 
nerve (Biernacki's symptom). The girdle pain, or feeling of constric- 
tion as if a cord were drawn about some part of the trunk, is common to 
this stage. There is often analgesia, the patient being insensible to the 
prick of a pin, or the sensation of pain being delayed. 

The third or paralytic stage is simply an aggravation of the symptoms 
of the preceding stage, and ushers in "the beginning of the end." The 
patient now finds it impossible to walk at all, or can only do so by invoking 
the support of two canes or crutches, or the assistance of friends. All 



688 LOCOMOTOR ATAXIA 

control over the bladder is lost; cystitis, muscular wasting and bed-sores 
may supervene. The patient becomes irritable, despondent and even de- 
.nented. He grows steadily weaker and more emaciated, and death re- 
Eeves him as the result of exhaustion, or he may succumb to infection 
resulting from catheterization, pneumonia, or other intercurrent disease. 

There are certain circulatory symptoms and trophic lesions often ac- 
companying tabes that have not been mentioned, such as rapid pulse, 
pseudoangina, aortic disease, and symptoms simulating Graves' disease. 

Among early symptoms generally present are various ocular pareses, 
the patient displaying ptosis, diplopia, light nyctalopia, and contraction 
of the field of vision, which may be progressive and end in complete ex- 
tinction of sight. The pareses may increase later or disappear. 

Certain peculiar formations appear at the joints. The large 
joints, the knee especially, are more frequently involved, although 
any joint may suffer. The bones become fragile in many cases 
of tabes, and the long bones especially are liable to fracture. Perfora- 
ting ulcer of the foot is not uncommon. Deformity and loss of nails are 
common, as well as herpes and purpura. 

Diagnosis: — A well-established case of ordinary tabes is easily recog- 
nized, and often before ataxia is manifest a diagnosis can be made. The 
disease may be mistaken for peripheral neuritis. The latter-named 
disease can usually be traced to some immediate cause, such as alcohol, 
lead or arsenic poisoning, diphtheria, some infectious fever, or diabetes 
or other constitutional disease. Neuritis progresses rapidly and may 
quickly spread to the upper extremities, and the ataxic stage occurs, if 
at all, usually within a few weeks or months. There is more tenderness 
in the muscles, more tendency to herpetic eruptions, greater motor weak- 
ness and wasting, paresthesia, more pronounced pain, but not fulgurant 
in type, knee-jerk increased, absence of Argyll-Robertson pupil. 

Alcoholic and arsenical poisoning resemble tabes more than the symp- 
toms of peripheral neuritis just described. In these cases there is more 
often knee-jerk, sharp pains more nearly resembling those of locomotor 
ataxia, incoordination, but less pronounced than the tabes, The gait 
is entirely different from that of tabes, being what is termed high " steppage " 
gait. Visceral and trophic disturbances are not nearly so common in 
peripheral neuritis as in tabes. 

The diagnosis from general paralysis, especially the spinal type, is 
attended with great difficulty, as the patient is ataxic, and there is loss 
of knee-jerk, the Argyll-Robertson pupil and many other symptoms 
similar to those of tabes. The progress of the disease, however, is more 
rapid than that of locomotor ataxia, and there are usually charac- 



LOCOMOTOR ATAXIA 689 

teristic signs of mental degeneration, such as loss of memory, irritable 
temper, incapacity for business, and hebetude. There is also hesitancy 
of speech and tremulousness of tongue, lips or hands. In general 
paralysis of the insane there are not present the lightning pains charac- 
teristic of locomotor ataxia. 

In ataxic paraplegia there is a staggering, tipsy gait, but not like the 
gait of tabes. The knee-jerk is exaggerated, ankle clonus develops, 
but lightning pains are very rare. The pupils are normal, and nys- 
tagmus is common to ataxic paraplegia but rarely found in tabes. 

In syringomyelia the lower limbs are usually paraplegic although 
they sometimes may be ataxic. The disease differs from tabes in that 
the limbs and upper part of the body are first affected, and there is a 
difference in the sensory disturbances, the temperature sense being first 
abolished. 

Hysteria may occasionally be mistaken for locomotor ataxia. 
Usually, however the knee-jerk is present and the pupils react to light. 
In rare instances, however, these signs are absent, when the diagnosis 
is more difficult. 

Prognosis: — The prognosis is very unfavorable, although the 
duration of life is not always by any means shortened. Death may 
occur from intercurrent disease. The prospect of retarding the progress 
of the disease is better the earlier the disease is treated. The prog- 
nosis is not influenced one way or the other by the fact that the patient 
has had syphilis. 

TreBtment: — Electricity has been employed and apparently with 
benefit in some cases. Static electricity and faradism applied by means 
of the wire brush have proved of benefit in relieving pain and restoring 
sensation to anesthetic areas. The constant galvanic current gradually 
increased to as many milliamperes as can be borne, one electrode placed 
over the sacrum, the other higher up on the spine, moved slowly up and 
down, tends to favorably modify nutrition. Electricity applied to the 
affected nerves in the ordinary ways sometimes relieves the various 
paralyses often occurring during the course of the disease. 

Hydrotherapy when properly employed exerts a favorable influence 
in some cases. No extremes of heat or cold should be used, but tepid 
baths (80 to 90 degrees) in carbonated saline water, accompanied by 
gentle friction of the body, are often very beneficial. 

Certain exercises designed to train the muscles in coordinated 
movements, markedly improve the ataxia in the majority of cases. 

The rest cure should be tried at the beginning of treatment, especially 
if there is much pain. The ''lymph cure" and testicular juice have 



690 MENINGITIS 

been highly recommended, and have produced remarkably beneficial 
results in many instances. 

Drug treatment is indispensable, and much can be done to retard 
the progress of the disease and ameliorate the symptoms by proper 
remedies. The general treatment of neural maladies is to be employed 
but some special measures have proved useful in tabes. The writer 
has had one cure result from the persistent use of strychnine pushed 
to full effect and sustained there, for prolonged periods — in fact the 
patient formed the strychnine habit and had taken the drug to the pro- 
duction of muscular tonicity for over two years when last seen by the 
writer. Arbutin, one to five grains a day, protects against cystitis. 
Heroin sometimes relieves the lightning pains quickly, but better 
remedies are to be found in solanine, cicutine and hyoscine, which do 
not conduce to habitual drugging. Silver oxide cured one case. 

III. DISEASES OF THE BRAIN AND 

MENINGES 

MENINGITIS 

Inflammation of the dura mater is known as pachymeningitis, 
that of the pia mater as leptomeningitis. Either may be acute or chronic, 
simple or infectious. 

Acute cerebral pachymeningitis may be primary when due to 
exposure to cold or heat, or secondary when caused by an infection, 
such as that from pneumonia, typhoid fever, cerebrospinal fever, or 
following injury, caries, syphilis or erysipelas. 

The attack begins with a chill, followed by fever running beyond 
105 ; convulsions quickly supervene, tonic or clonic, with delirium, 
mania, violent vomiting and retraction of the head. The convulsions 
may begin in one set of muscles and spread. Paralysis is a late symp- 
tom. The pupils are dilated irregularly, and optic neuritis occurs. 
Strabismus may appear, diplopia or hemianopsia, and choked disk. 
The other special senses are hyperacute at first, the hearing gradually 
becoming dull. Spasm of facial muscles may be followed by paralysis. 
Involvement of the basilar membranes causes bulbar symptoms. The 
duration is variable. Later, stupor, paralysis and convulsions indicate 
compression. The acute stage lasts a week or ten days, sometimes 
ending by crisis, more frequently by lysis, with tedious and imperfect 
convalescence. Death may follow early severe symptoms. The 
prognosis is worse in children. Most cases that recover have retained 
some defect, such as blindness or deafness, or some form of paralysis. 



MENINGITIS 691 

Tre3tment: — Put the patient to bed in a dark room, which must be 
kept cool and quiet. Hyperpyrexia may require the application of cold, 
and venesection in suitable cases. Gelseminine seems better suited to 
these cases than aconitine, but if elimination is defective, veratrine is 
a better selection. Either should be rapidly pushed to full effect — a 
granule of either given in solution every ten to thirty minutes, or a full 
dose administered at once hypodermically. If anything is required 
for the convulsions solanine may be given, gr. 1-12 every hour until effect. 
As the disease progresses cactin, and later digitalin or apocynin, will 
be required to sustain the heart. Infectious cases should be promptly 
and vigorously treated by saturation with calcium sulphide, and nuclein 
solution. Any accessible suppurative focus should be evacuated at once 
and thoroughly disinfected. As the acute symptoms subside the absorb- 
ent combination should be vigorously pushed to full effect. Epilepsy 
and other sequels require their appropriate treatment. 

Chronic meningitis usually follows the acute attacks. In some cases 
the malady is at first latent. It may also follow sunstroke, syphilis or 
traumatism. The symptoms are persistent dull headache, increased 
by sleeping or lying down, or exposure to heat; pain in the neck radiating 
towards the shoulders; general spastic paresis, affections of the special 
senses, vertigo and epilepsy. The diagnosis from cerebritis is made by 
the absence of marked mental degeneration and the great spasticity 
present. In cerebral tumor, optic neurites with local symptoms are 
characteristic, while in hydrocephalus the enlargement of the cranium 
suffices. Complete permanent recovery is rare. The malady may, 
however, last for many years. In children it checks development and 
shortens life. Sight and hearing are generally permanently affected. 
The treatment is that of the acute form, with persistence in the use of 
absorbents. Sometime the application of iodoform ointment to the scalp 
may prove beneficial. 

Hemorrhagic Pachymeningitis: — The most frequent cause of this 
affection is prolonged alcoholism, except as it occurs in epilepsy or mania. 
The symptoms develop insidiously, the patient complaining of headache, 
followed by dementia, loss of memory and incoherence with periods 
of excitement. Uremia may supervene from temporary disability of 
the kidneys. Recovery may ensue, followed by recurrence within a 
week, with muscular weakness, worse on one side of the body. The 
mental symptoms become more prominent, with delirium, generai 
tremor, early spasticity, etc. Diagnosis is difficult, but the disease may 
be inferred from the history, the early development of spastic contrac- 
tions and of mental aberrations. Apoplexy and nephritis present 



692 HYDROCEPHALUS 

symptoms not manifest in this malady. The patient dies usually within 
ten days. The treatment is that of acute meningitis. Surgical 
intervention may prove successful. The toxemia may be relieved by 
blood-washing — abstracting blood and injecting saline solution. 

Cerebral leptomeningitis is usually an acute infection. The symp- 
toms are headache, delirium, insomnia, coma, vomiting, constipation, 
fast pulse, hyperpyrexia, great mental anxiety, fever of the hectic type 
and rapidly developed. Convulsions and rigidity are less common; 
the headache less intense than in pachymeningitis. Suddenly devel- 
oping local paralysis and spasms are frequent. The tache cerebrale 
may be elicited. The head is retracted. 

Kernig's Sign: The patient cannot extend the leg when the thigh 
is flexed at a right angle with the body. 

The patient generally dies within ten days, but crisis may occur or 
chronic septic inflammation follow. The treatment is that of pachy- 
meningitis with especial attention paid to the septic element. 

HYDROCEPHALUS 

The acute form may follow acute meningeal inflammation. It 
affects infants, especially marasmics. The symptoms are those of sub- 
acute meningitis with fewer convulsions and less fever. Muscular 
rigidity is marked. The cause is usually autointoxication, according 
to Pierce. The head enlarges, the fontanelles bulge and their tension 
increases. The eyes project from the sockets, the whites being 
especially visible above the cornea. The forehead bulges also and the 
sutures separate. The hydrocephalic cry is common. Percussion on 
the skull often produces an apparent tympanitic noise, and auscul- 
tation detects a bruit, synchronous with the pulse. Tetany supervenes. 
The disease consists of a subacute meningitis with effusion of serum, 
especially in the ventricles. 

The prognosis is bad. In severe cases the patient dies within a few 
months or the attack may subside, leaving a permanent enlargement 
of the head, as a rule with mental impairment and spastic paralysis, 
but not necessarily. 

Treatment should begin by sustaining the mother's health and 
ensuring her pleasant hygienic surroundings during pregnancy. Daily 
inunctions of cod-liver oil markedly increase the nutrition of the child. 
Calx iodata should be given to free eliminants of debris, and strengthen 
the cell-walls. Solanine is a better remedy for the spasms than the 
bromides, less depressing and less likely to disturb the digestion. Iodo- 



APHASIA 693 

form ointment applied over the scalp may prove of value. The bowels 
must be kept clear and disinfected. The hygienic influences are of the 
utmost importance: Fresh air and sunlight are the best remedies as 
prophylactics and cures. 

CHRONIC HYDROCEPHALUS 

The chronic form follows acute attacks, or may develop before birth 
or soon after. The causes are not known, but it may be assigned to bad 
hygienic surroundings, innutrition and dyscrasias of the mother. The 
head may be so enlarged as to interfere with birth. The lateral 
ventricles are :greatly distended, the choroid plexuses vascular; the 
cerebrel tissues greatly compressed, the basal ganglia flattened, the 
bones thin, the gaps partly filled in by Wormian bones. The symptoms 
resemble those of the acute form but are less pronounced. The reflexes 
are increased. The child sits, stands and walks late, becoming in 
time weak and spastic. The mental condition varies from imbecility 
to normality. The diagnosis is to be made from rickets, in which the 
head is square rather than round, and the ends of long bones are 
enlarged. When the disease develops late in life the patient suffers 
from headache, the gait becomes gradually irregular and ataxic, with 
a peculiar tendency to spasticity. Prolonged attacks of coma sometimes 
occur, with slow pulse from pressure on the pneumogastric nuclei. 
Optic neuritis occurs early and progresses rapidly. Suppuration may 
ensue. A serous form has been described by Quincke, occurring sud- 
denly in children, with intense headache, cerebral pressure, slow pulse 
and choked disk, retraction of the head but no fever. 

Treatment: — For the relief of pain we may choose between gelsem- 
inine for the febrile stages, solanine if spasm be marked or convulsions, 
cicutine hydrobromate for mental irritability or derangement. The 
bowels must be kept clear and aseptic. Absorption should be urged. 
The surroundings should be made hygienic, the diet carefully arranged 
and no precaution omitted which would tend to avoid irritation and 
favor the nutrition of the patient. The inunction of hot cod-liver oil is 
especially advised in the case of children. 

APHASIA 

In this malady the power of speech is disturbed. It is due to a lesion 
of the cerebral speech center, not to an affection of the tongue or its 
nerves, or of the coordinating tracts. It is divided into motor or sensory. 
Motor aphasia is also known as aphemia. One variety is caused by a 



694 MALFORMATIONS 

lesion of the foot of the left third frontal convolution; another by a lesion 
at the foot of the second central convolution. Total destruction of the 
first or Broca's convolution in right-handed persons makes speech 
impossible, until the corresponding convolution on the right side develops. 
In most cases we also find agraphia, or inability to write, possibly due to 
a lesion of the caudal extremity of the mediofrontal convolution. It 
almost always results when Broca's center is destroyed. Disturbance 
of pantomine expression nearly always accompanies disturbance of 
speech. This is known as amemia when due to cerebral disease, or 
paramemia when the signs the patient endeavors to employ are confused. 
Sensory or receptive aphasia may be auditory or word deafness, 
visual or word-blindness, or apraxia or mind-blindness. The first is due 
to a lesion in the posterior third or first and second temporal convolu- 
tions. The patient is unable to read aloud correctly, or to verify what 
he reads by hearing. If complete he cannot echo spoken words. Motor 
forms may accompany it. Music deafness may be associated or 
absent. Between the auditory centers at the base of the brain and 
those in the left temporal lobe are also entering tracts for hearing, 
a lesion of which also causes a form of word-deafness. Word-blindness 
depends on lesions of the corresponding center for the storage of visual 
image , which is located by Ferrier in the angulooccipital region or the 
lateral surface of the hemisphere. Alexia, the inability to read, will be 
accompanied by agraphia, the inability to write. Examining for mind- 
blindness we seek to determine if the patient recognizes objects. Some- 
times he cannot recognize friends by the sound of their voices. Con- 
ducting aphasias are due to lesions of the tracts associating regions 
concerned in the mechanism of speech. We therefore, have paragraphia 
and paramemia, the misuse of words in writing or of signs; paraplexia, 
the misuse of syllables or words in reading; and dyslexia, difficulty in 
reading. 

MALFORMATIONS 

The most important of these is meningocele, a protrusion of the 
meninges from the skull or the spinal cord. Usually such tumors are 
covered by the skin. In the skull they are most frequent from the an- 
terior portion, as the bones are thin and the fontenelle offers oppor- 
tunities. The cause is an increase of the pressure from excess of fluid. 
Such children usually die before the expiration of a year. Besides the 
protrusion the symptoms are drowsiness, mental weakness, paresis and 
convulsions. The treatment is surgical and very unsatisfactory. 



APOPLEXY 695 

APOPLEXY 

This term designates an effusion of blood into the cerebral tissues. 
It is most frequently derived from the lenticulostriate arteries. The 
accident is known as a stroke, which may be due to hemorrhage, throm- 
bosis or embolism. Predisposing causes are alcoholism, syphilis and 
other infections, arteriosclerosis and heredity; plethora from overeating 
may be added. Exciting causes are physical and mental strain. Strokes 
occur more frequently at night or in the early morning, and often follow 
a period of particularly good feeling, or euphoria. Sometimes one is pre- 
ceded by vertigo or brief attacks of cerebral congestion. It may follow 
overexcitement or exertion, straining at stool or a particularly heavy 
meal. The attack is characterized by a sudden loss of consciousness, 
preceded by thick speech or motor aphasia, the face flushing, extreme 
objective vertigo, the patient falling unconscious; respiration is stertor- 
ous. Clonic convulsions may precede paralysis, which is usually on 
the opposite side of the body from the hemorrhage. Slight fever arises, 
while marked restlessness is succeeded by coma. If not profound, the 
paralyzed side is found to be hyperesthetic. The temperature increases 
on the paralyzed side. Hyperpyrexia is rare and generally fatal. As 
the patient recovers some consciousness he may move the healthy side, 
but not that which is paralyzed. There is apt to be retention of the 
urine. The deep reflexes are lessened. The eyes may be fixed, or turned 
from the paralyzed side; or if convulsions occurred, the head and eyes 
may be turned towards the paralyzed side. 

In non-fatal cases improvement begins in three hours. The coma 
gradually lightens, the reflexes reappear and the patient may recover con- 
trol over some of the muscles. Lying on the weak arm may cause pres- 
sure paralysis. The power of speech gradually returns, with some dif- 
ficulty remaining perhaps permanently. There is difficulty in swallow- 
ing and dribbling of saliva. Taste is normal but the tongue protrudes 
to the paralyzed side, the face being drawn towards the sound one. 

The paralyzed muscles do not degenerate, and the only wasting is 
that due to disuse. In a few weeks the patient will be moving about 
with a cane, the gait being characteristic. The arm improves more 
slowly than the limb, probably because it is not exercised as necessarily. 
The flexors tend to contract. Secondary degeneration of the nerve 
structures may follow, and extend to the other side of the spinal cord. 
Disuse of the muscles and joints leads also to trophic changes. Much 
of the disability supposed to be directly due to paralysis is really due 
to disuse. We have known a masseur cure paralysis of an arm in a few 



696 APOPLEXY 

moments by vigorous manipulation, the adhesions being broken up 
with distinctly audible sounds. Neuritis may also follow in the paralyzed 
part. The reaction of degeneration does not occur in muscles paralyzed 
by cerebral lesions. Vasomotor debility may cause sweating on the 
palsied side. 

Cerebral hemorrhages usually follow disease of the blood-vessels, 
with degeneration of their walls and the formation of minute aneurisms. 
These may be caused by endo- and periarteritis. Fatty degeneration 
occurs also in purpura and other ■ marasmic conditions, and in acute 
infections. These affect the smaller vessels, atheroma occurring in the 
larger ones. Hemorrhages occur in frequency as follows: The caudate 
and lenticular nuclei, meninges and cortex, centrum ovale, optic thala- 
mus, pons, cerebellum and medulla. 

When a hemorrhage occurs some nerve fibers are violently ruptured. 
Inflammation follows and around the zone of inflammation is another 
of edema, so that even when a small number of fibers are torn many 
others are inhibited by infiltration and pressure. The blood effused 
soon coagulates; the inflammation subsides; the serum and inflamma- 
tory lymph are gradually absorbed, as well as the clots, although the 
latter may leave a cyst containing fluid or else a scar, which is pigmented. 
As absorption proceeds the pressure is reduced and the inhibition of 
nerve function is gradually removed. For this reason the larger por- 
tion of the disability caused by such a stroke will disappear in time, but 
the presence of a scar will prevent reunion of the broken fibers. For 
this reason, while nearly all the symptoms will disappear in time, it is 
almost certain that some nerve fibers will be permanently disabled from 
resuming their function. 

Diagnosis: — Embolism may be diagnosed by the history of heart- 
disease, by the slight disturbance of consciousness and the permanence 
of paralysis, which is sharply defined. A preexisting heart-murmur 
may be found to have altered or disappeared. Thrombosis may be 
inferred if it has occurred in other parts of the body with extensive 
arterial degeneration. The onset is slow and progressive. 

Diagnosis: — Half the cases recover from the attack, three-fourths 
of whom will have recurrence. In general, therefore, the life will be 
shortened and the working power impaired. 

Treatment: — Put the patient in bed, with the head partly elevated; 
apply ice to the head and heat to the feet, but remembering that the 
patient is unconscious and anesthetic, do not freeze the scalp or burn 
the feet. Frictions to the legs restore circulation. Hot mustard baths 
or poultices are of value. False teeth may occasion strangulation and 



APOPLEXY 697 

should be removed. It may be necessary to prevent this by drawing 
out the tongue. Respiration can be aided by gently and firmly raising 
the larynx with the tips of the thumb and index finger. The inhala- 
tion of oxygen should prove of great value. To relieve the suffering 
brain, prompt and vigorous catharsis should be secured by giving croton 
oil, one to four drops, placed upon the tongue or in solution. General 
or local bleeding is useful in cases that will bear it. Absolute quiet 
must be enjoined, and no food given for 48 hours. After that very 
small quantities, not to exceed two ounces of fluid food, may be admin- 
istered every two to four hours. The bowels should be kept clear by 
half-pint enemas of cold saturated salt solution. Nothing stimulating 
should be allowed unless heart-failure becomes imminent, which may 
be warded off by hypodermics of strychnine. The patient should not 
be allowed to sit up for three weeks, and at first then only for a few 
moments until the cerebral circulation is adjusted to the new conditions. 
Massage, however, can be commenced at the expiration of one week. 
Fever and increased vascular tension are best treated by veratrine or 
aconitine, unless delirium is present, in which case gelseminine is preferable. 
Either should be given in small and frequent doses, regulated by the 
effect upon the pulse. It is imperative that the physician see that the 
bladder is emptied at regular intervals. As soon as the inflammation 
has subsided efforts should be made to promote absorption of the effused 
matter by the use of the absorbent remedies so frequently advised in 
this section.* These may usually be given with advantage for a period 
of one or two months. At the same time, after two weeks have elapsed 
efforts should be made to arouse the nerves to action, the remedies being 
galvanism and strychnine. When strychnine has been pushed to the 
limit and the patient is apparently unable to secure further benefit from 
it, decided improvement can yet be secured by substituting thebaine 
and pushing it likewise. The doses are the same as those of strychnine; 
the indication of full action likewise the same. These patients must 
not allow themselves to sink into disability from want of physical effort, 
or in a dread of exertion which is much like that felt by men when they 
first discontinue the crutch after a broken leg has healed. Neverthe- 
less the man who has had a stroke must consider that his active life- 
work is done, and the balance of his terrestrial existence is to be devoted 
not to business or labor, but to keeping himself in health and prolong- 
ing his life. 



*Mercury biniodide gr. 3-67, arsenic iodide gr. 1-67; phytolaccin and iodoform aa gr. 1-2. 
Give this three to seven times a day, just avoiding toxic effects. 



698 ENCEPHALITIS 

ENCEPHALITIS 

Inflammation of the brain substance may be caused by injuries, 
general or local infections, or by such affections as arteriosclerosis, 
which interfere with its nutrition. In the acute form the symptoms 
are mental confusion, slight fever and paresis of the extremities, some- 
times convulsions or paralysis of the third nerve. The onset is rapid 
and hemiplegia may be present. The patient dies within ten days of 
cerebral compression, or of paralysis of the heart or lung centers. The 
disease is an inflammation of the brain-cells, with minute hemorrhages 
or hemorrhagic effusions. Optic neuritis may be present but seldom 
choked disk. 

In the chronic septic form the same symptoms are present in mod- 
erate severity, sometimes with chills and fever, more frequently per- 
haps a subnormal temperature. This form generally follows infectious 
disease of the ear or nose. The malady is generally local, but there 
may be multiple suppurative foci. Convulsions .and paralysis depend 
upon the irritation or destruction of the part in which the disease occurs. 
Abscess is most frequently in the cerebellum due to extension from the 
middle ear. The cerebellar gait will then be a feature, while convul- 
sions and paralysis ensue if the abscess is in the motor area; deafness 
if in the sphenotemporal lobe; asteriognosis and mind-blindness if in 
the posterior parietal; and mental stupor ensues if in the frontal lobes. 
The diagnosis from brain tumor is made by the history, and the rapid 
progress in abscess. The patient dies within a few months. Some- 
times the pus is encapsulated and the patient lives for years, although 
liable at any time to develop acute fatal symptoms. 

The treatment is preventive, by the radical treatment of the oral or 
nasal disease, or simply surgical when the abscess has developed. 

Chronic polioencephalitis superior presents the symptoms of the 
mild simple type, without pain but with involvement of the third nerve 
affording ptosis, exophthalmos, iridoplegia and external strabismus, 
unless the sixth nerve is affected. 

Polioencephalitis inferior also presents the symptoms of the ordi- 
nary form with those indicating the involvement of the nuclei of the 
fourth and lower cranial nerves. There is no fever. The paresis indi- 
cates which nerves are involved. The prognosis is bad, diagnosis easy. 
Since consciousness is unimpaired the treatment consists in quiet, cold 
to the head, keeping up nutrition and keeping down vascular pressure, 
careful regulation of the diet so as to sustain nutrition; the absorbents 
should be employed freely, followed by zinc phosphide and neuro-leci- 



NERVOUS SYPHILIS 699 

thin. With these powerful remedies and the recognition of the impera- 
tive necessity of preventing fecal toxemia, the prognosis of many of 
these affections will be vastly improved. 

BRAIN TUMOR 

Tumors of the brain are most common in young adults, their relative 
frequency occurring as follows: Tubercle, fibroma, sarcoma, glioma, 
carcinoma, and gumma. There may be a hereditary disposition to 
brain tumor. Gumma occurs in older persons. The general symptoms 
consist in mental excitement, reflex or cerebral vomiting, vertigo, choked 
disk and dull headache. The vomiting is of cerebral type and does 
not depend on food or digestion. Convulsions may be general or local- 
ized. Special symptoms indicate the location of the growth in the same 
manner as they do in abscess. Mental dullness or incoherency is spe- 
cially indicative of disease in the frontal lobes. Tenderness over the 
tumor is a valuable sign if the growth is in the cortex, especially if devel- 
oped by percussion. In the motor area the tumor will cause convul- 
sions followed by paralysis; in the parietal region sensory changes with 
mind-blindness; in the temporosphenoidal lobe word-deafness; in 
Broca's region motor aphasia; in the corpus striatum paresis of the 
opposite side without convulsions, but with disturbed temperature, some- 
times hyperpyrexia; in the optic thalamus hemianopsia and probably 
pupillary inaction; in the corpus callosum the same symptoms as sub- 
cortical tumors; in the cerebellum choked disk, ataxia, disturbed knee- 
jerk; in the gyrus uncinatus, perversion of smell; in the gyrus fornica- 
tus, loss of smell; in the cuneus mind-blindness and hemianopsia with- 
out Wernicke's sign; disturbance of taste when its centers are involved. 
Pain is much greater if the meninges are affected. The growth is always 
surrounded by zones of inflammation and of edema. The diagnosis is 
difficult. Abscess may be recognized by the previous existence of septic 
disease of the ear or nose, and by the alterations of temperature, of the 
septic type. In meningitis we have the pain but not the local symptoms 
or intense choked disk. The prognosis is very bad; the treatment exclu- 
sively surgical, except with gummata. Here, as the utmost haste is 
necessary to limit destruction of tissue, the absorbent combination should 
be pushed vigorously. 

NERVOUS SYPHILIS 

Syphilis affects the nervous tissues in the form of gummata or as 
the parasyphilis of toxin causation, the "quaternary stage." The latter 



7 oo DEMENTIA PARALYTICA 

does not cause specific lesions but is transmitted as a morbid tendency, 
appearing in the children as ataxia, or other neuroses. How many 
dyscrasias are due to syphilitic heredity is uncertain. 

Tertiary lesions may appear as endarteritis obliterans, gummata or 
gummatous meningitis. The attack occurs some years after the initial 
lesion, with drowsiness by day and wakefulness by night, not due to 
feeble circulation; and persistent headache, mental dullness, failing 
memory but no delusions; diplopia, ocular palsies, strabismus, or restric- 
tion of ocular movement; general debility, exaggerated reflexes, local 
palsies, acute optic atrophy and neuritis, rarely choked disk, occasional 
convulsions, and various anesthesias and varied paresthesia. Syphilitic 
palsies are rarely complete or unrelenting. Early cranial palsies are 
diagnostically significant. 

Spinal syphilis usually is accompanied by cerebral lesions. Symp- 
toms are paresthesia of the lower limbs, with weakness and rigidity, incon- 
tinence or difficult urination, heightened reflexes, ankle clonus, hyper- 
or hypo-esthesia in irregular patches, disturbed coordination and Rom- 
berg's symptom. The reflexes are disproportionate to the palsy and 
loss of muscular tone. Contractures are infrequent. Wasting and 
fibrillary contractions are rare but cyanosis with cold extremities frequent. 
Bedsores are rare. The symptoms are not symmetrical. Remissions 
are also distinctive of the specific malady. The course is indefinite, 
leading to degeneration if not well treated. Occasionally sudden death 
occurs. The girdle sense of myelitis is wanting. 

The prognosis is good if early recognized and intelligently treated. 
Haste is essential, since nerve cells and fibers once destroyed can not 
be rebuilt by drugs. 

The absorbent combination should be vigorously pushed to full effect 
and this sustained as long as may be requisite. 

. DEMENTIA PARALYTICA 

This disease is also known as paresis or general paralysis of the insane. 
It consists in a progressive degeneration of the brain tissue, with peculiar 
mental conditions ending in dementia. It is believed to be a parasyph- 
ilitic affection, the patient being born neurotic, of syphilitic parents. It 
is much more frequent in men. Predisposing causes are alcoholism, 
sexual excess and excessive mental exertion, more especially the combina- 
tion of all three. Syphilis is traced in three-fourths of the cases. Sun- 
stroke, exposure, injury and acute infections sometimes are excitants. 
It is most common about the 30th year, in married men. 



MINOR CEREBRAL MALADIES. 701 

The first stage is that of excitement. The patient becomes irritable, 
over-annoyed by trifles, slovenly in his business, easily fatigued and in- 
attentive, extravagant and unwise. This is followed by a condition of 
exaltation, in which he is very happy, prosperous and successful in all 
matters. Delusions of grandeur are periodic and interrupted by out- 
bursts of violence, especially if he develops periodic dipsomania. If 
early put under restraint apparent or real remissions may occur, but usu- 
ally dementia supervenes gradually and increases until his mentality is 
extinguished. The hand-writing becomes wavering, facial tremor oc- 
curs and tremor of the tongue, the speech is thick and stuttering, knee- 
jerks increased, pupils unequal and sluggish; the sexual function weakens 
early; dribbling of urine occurs; the appetite is gluttonous and fat accu- 
mulates. Convulsions, hemiplegia and apoplexy may occur. As dementia 
crawls on the patient grows quiet, sleeps by day, is very forgetful, does not 
recognize friends or take interest in anything. He grows dirty and childish; 
even then when excited he may have delusions of grandeur or persecution. 

In another type the malady begins with dementia, without grandeur 
or any delusions at all. Tremors and the other symptoms appear as 
above described. In still another form the type is that of hypochondria 
and neurasthenia. The patient has vast distresses in the head, or mi- 
graine, pain in the back and limbs, or dull pain in the epigastrium. In 
the course of a year mental derangement appears, with suspicion, de- 
mentia, delusions of persecution, etc., with violent outbreaks. In cases 
of acquired syphilis similar symptoms may follow tertiary deposits, and 
disappear under treatment. A similar condition also occurs from alcohol, 
with progressive mental deterioration. 

The blood-vessels are thickened, the nerve cells degenerated, the con- 
nective tissue hyperplastic, the dura vascular, the brain mass atrophied, 
the cerebrospinal fluid increasing. All the membranes are thickened. 
In fact the brain is cirrhotic, the neurons fatty. The cord may partic- 
ipate in the disease and ataxic phenomena complicate the picture. The 
treatment is uncertain. Antisyphilitic treatment if employed early some- 
times stops the course of the disease. Excepting this we have little from 
which to hope, .although benefit may result from the use of nuclein or 
neuro-lecithin, as well as from the accessory remedies, massage and various 
forms of electricity and hydropathy. 

MINOR CEREBRAL MALADIES 

Cerebral hyperemia results from hypertrophy or over-action of the 
heart, excessive mental activity, vasomotor spasm of the periphery, and 



702 MINOR CEREBRAL MALADIES 

the action of any agent that dilates the cerebral vessels, such as alcohol, 
the nitrites, and the atropine group. The remedies are the cardiac de- 
pressants, gelseminine, veratrine and aconitine, as named, and quick 
and powerful action on the bowels as by elaterin. 

Cerebral congestion occurs when the bloodvessels are engorged by 
back pressure, as in disease impairing the tricuspid valves, pressure on 
the superior cava by tumors, suffocation, strangling, and excessive and 
prolonged muscular strain with breath held. The remedies are those 
required by the condition, but emergency may demand venesection, or 
quick depletion of the bulk of the blood by exosmotic enemas or purges. 

In hyperemia we see evidences of irritation— headache, vertigo, in- 
somnia, quick and hard pulse, bright eyes, and a choleric temper, flashes 
of light, and even convulsions. In the latter the patient and his senses 
are sluggish, dull, the temperature subnormal, lips cyanotic, and the 
evidences of advanced obstructive circulatory disease are manifest. 

Cerebral anemia may be due to exhausting discharges, hemorrhages, 
feebleness of the heart, relaxation of the abdominal vessels, the quick 
evacuation of the bladder or of ascitic fluid. Brunton has illustrated 
the syncope following a person's rising from recumbency to empty the 
bladder, the release of abdominal pressure being followed by the blood 
collecting in the abdominal vessels and failing to reach the brain- 
sudden faintness may follow, and may prove fatal in those whose heart- 
force is deficient anyhow. The writer recently lost a relative who, suffer- 
ing in advanced age from a fatty heart died instantly when rising after 
kneeling in prayer. 

The symptoms are pallor, feebleness, vertigo, dull headache, flashes 
and flushes, rapid respiration, fast weak pulse, both increased by slight 
exertion, coolness of the skin and extremities, profuse cool sweat in sud- 
denly developed anemias, and fainting fits. The ordinary evidences of 
general anemia are present. The treatment depends on the cause. Glon- 
oin most quickly returns the blood to the head; atropine prolongs this 
effect and acts quicker for the glonoin, and brucine strengthens the heart. 
Give glonoin and atropine gr. 1-250 each, and brucine gr. 1-134, together, 
every five minutes till the face flushes, then less frequently. Keep the 
head low and the feet raised above its level. 

Cerebral edema occurs in nephritis, senile and other atrophies, and 
in the later stages of chronic alcoholism. The symptoms are those of 
anemia and dementia. 

Embolism: — Vegetations from the heart are carried into the cerebral 
arteries, cutting off the circulation, and if septic occasioning septic ab- 
scess. During pregnancy and in some infections like diphtheria and pneu- 



ACUTE DELIRIOUS MANIA 7°3 

monia the blood is abnormally coagulable and fragments of heart clots 
are likewise washed into the arteries. If not septic the cerebral area 
affected softens, being red at first from hemorrhages or infarction, 
yellow as the hemoglobin is absorbed, white in the commissural tracts. 
The neural tissue disintegrates and the connective proliferates forming 
a cicatrix. Large tracts may result in a cyst. 

Thrombi form in the cerebral arteries from disease of their walls, 
extensions, traumatisms, aneurisms, blood diseases, or embolisms; caus- 
ing changes in the walls, retarding the current, etc. In the veins or si- 
nuses they form from general or local disease. In primary thrombosis 
the superior longitudinal sinus is more frequently affected. In secondary 
forms it is the part nearest the causal malady. 

In embolism the onset is sudden with loss of consciousness, shock, 
coma, convulsions and delirium, three varieties being distinguished as the 
apopleptic, convulsive and delirious. Thrombosis usually begins gradually 
with vague pains, numbness, tingling, headache and vertigo. The mind 
weakens and strength decays. Other symptoms depend on the location 
of the lesion. Treatment is not very effective. Enjoin rest, meet symp- 
toms, sustain strength and quiet vascular excitement, treat the causal mal- 
ady when possible, and establish a salutary regime. In secondary throm- 
bosis surgical aid may release pent up collections and remove carious 
bone. Keep up elimination. Employ the absorbents when indicated. 
Stimulate tissue restoration by means of zinc phosphide and neuro-lecithin. 

ACUTE DELIRIOUS MANIA 

This malady is an acute periencephalitis, displaying minute hemor- 
rhages in the meninges and gray matter. It occurs in neurotics, after 
alcoholic or sexual excesses, prolonged anxiety, parturition, menstrua- 
tion, insolation, acute infections especially pneumonia, and sometimes 
without evident cause. 

The patient is restless, melancholy or anxious, .has anorexia, consti- 
pation, and loses flesh. The mind weakens. Bad dreams or night- 
mares occur. Fear of mental disease is present but merges into an at- 
titude of defiance or quarrelsomeness, passing into violent delirium; be- 
ginning suddenly, confusional, with intense excitement, fear, delusions 
of persecution and hallucinations. The tongue is dry, pulse fast and 
weak, petechiae appear and fever rises to 105 or more. Hyperesthesia is 
present. This stage passes rapidly into that of collapse, with higher fever, 
stupor, growing debility, eyes hollow, low muttering, skin dry and cyanotic, 
pupils dilated, and death within three days. There may be remissions. 



704 VERTIGO 

Diagnosis is not easy. The fever distinguishes from ordinary mania. 
In delirium tremens we see the tremors. The course may be extended 
to several weeks. The prognosis is always bad, worse for men. 

The treatment should be by the most active antiphlogosis. Vene- 
section may be employed freely, and elaterin is always advisable, but 
gelseminine should be promptly and strongly pushed to production of 
ptosis and kept up. Meanwhile the absorbent combination is to be 
employed energetically. Hyoscine is the best remedy to secure sleep. 
Cicutine hydrobromate and solanine are useful. The strength must be 
sustained by suitable diet, and heart tonics employed as soon as the symp- 
toms admit. 

PARALYSIS OF CHILDREN 

Several forms of paralysis have been described as occurring in children 
especially. These include hemiplegias, the polioencephalitis of Struem- 
pell, congenital encephalitis of Virchow, and meningoencephalitis, and 
a majority of cases to which no lesion has been attached. Atrophy, 
hypertrophy and sclerosis follow, or the parencephalia described by Heschl 
in which the brain tissue is replaced by cysts. 

The causes are unknown. The symptoms resemble those of similar 
maladies in adults — sudden loss of consciousness, convulsions, always 
fever, hemiplegia, mental deficiency, the course resembling that of adults. 

Other palsies date from birth and may be due to the misuse of forceps; 
occurring as paraplegias, with increased reflexes, spasticity, and lack of 
mental development. Van Gehuchten concludes that these cases occur 
in premature children more frequently and not after difficult labors. The 
prognosis is never very good. The treatment is that of adult cases. Men- 
tal and muscular training is important. 

IV. DISEASES OF UNKNOWN PATH- 
OLOGY, Etc. 

VERTIGO 

In objective vertigo the patient has a sensation as if visible objects 
at rest were moving; in subjective vertigo he feels as if he himself were 
moving. 

Etiology: — Vertigo may be due to blood conditions, anemia or hyper- 
emia; to toxins, tobacco, autotoxemia, lead, alcohol; to arteriosclerosis 
and other causes of hypertension; to aural irritations, neuroses, reflex 
causes and such mechanical causes as swinging, sea and car-sickness. 



INSOMNIA 705 

Symptoms: — The paroxysms are sudden and brief. Faintness with 
apprehension attend. Mental confusion ensues, with nausea, the pa- 
tient catching at firm objects to keep from falling. Lowering the head 
usually relieves. There will be symptoms of the causal malady, which 
may be disease of the labyrinth, the cerebellum and its peduncles, de- 
generation of kidney structures, neurasthenia, hysteria, sources of reflex 
irritation an where, astigmatism or other ocular maladies; dyspepsia, 
indigestion or constipation, vertigo being very frequent with pyrosis; 
tea or coffee in excess, deficient renal action, feebleness of the heart, fever 
or determination of the blood to or from the head from any cause 
so as to disturb the cerebral circulatory equilibrium. 

It will thus be seen that vertigo is a symptom that may present itself 
in many diverse conditions and diseases. The diagnosis is always there- 
fore as to the underlying malady. The prognosis depends on the cura- 
bility of the cause. So does the treatment. Cerebral anemia demands 
lowering of the head, as hyperemia requires it to be elevated. Therapeu- 
tically we accomplish this by the administration of a sufficiency of aconi- 
tine, veratrine or gelseminine on the one hand, or of glonoin, atropine 
and strychnine on the other. The bowels must in all cases be made 
and kept clear and aseptic, and the renal elimination maintained. Weak 
heart requires the patient to lie still until the tonics given have had time 
to act. Persistent vertigo depends on a continuously acting cause. 

INSOMNIA 

The need for sleep is so imperative that it is impossible for a healthy 
person to remain awake indefinitely. The time required differs largely, 
and Franklin's maxim of "six hours for a man, seven for a woman, and 
eight for a fool," only applies to those who are suited by it. Few men 
require less than six hours, and exhausting work, physical or mental, 
may necessitate much more. Children should have more than that; in 
fact, as much as their natures seem to demand. 

The tendency to insomnia may be hereditary. It is more apt to show 
in brain workers, the toxins inducing sleep being developed by muscular 
exercise. Gout and other causes of increased vascular pressure cause 
it directly, and as primary causes of tension we may mention autotoxe- 
mias of various forms. Feebleness of the heart causes somnolence from 
cerebral anemia while standing or sitting up, the weak vessels of the brain 
collapsing when the patient lies down and permitting a cerebral hyperemia 
that induces wakefulness. Syphilis, malaria, uremia, the saturnine and 
other cachexias, induce wakefulness. Neurasthenia probably acts through 



706 INSOMNIA 

the vasomotor conditions above noted. Worry and other overpowering 
emotions prevent sleep or render it unrefreshing. Some form the habit 
of sleeping only during a certain period of the night or day, while other 
awake at a fixed time no matter when they retire. 

Loss of needed sleep causes irritability and mental fatigue, especially 
in adults. This will increase until, as in the days of the Inquisition when 
forced wakefulness was employed as a method of torture, insanity results. 
In fact, there is some danger of this whenever any patient fails to sleep 
when all obvious difficulties have been removed. 

In treating insomnia the first duty is to ascertain if the causes are 
removable. Against them the therapeutics should be directed. The 
fulfilment of this indication will necessitate a close inquiry into the 
personal habits, and a shrewd surmise as to certain matters which the 
patient may not care to discuss or to tell his adviser the truth about. 
The sexual life must be investigated, not necessarily by direct ques- 
tioning, and properly regulated. Men must learn to leave the cares of 
the office at the office, and to wrench the thoughts away from disquieting 
matters that inhibit sleep. If business prevents sleep, give up business; 
for surely insanity cannot further business interests. Men's need for 
bodily exercise may be measured by their muscular development — and 
as most men pride themselves on manly strength the suggestion that a 
man must exercise in proportion to his muscular powers to retain 
health will induce the majority to acquiesce in the necessity of physical 
labor. 

The drug therapeutics first takes into consideration the vasomotor 
conditions. If the heart is so weak that on lying down the cerebral 
vessels dilate and prevent sleep, a suitable dose of digitalin (average 
gr. 3-07) or of any cardiac tonic, will give certain relief. If on the other 
hand there is cerebral activity from hyperemia and abnormal vascular 
tension a few granules of aconitine, veratrine or gelseminine will restore 
normal conditions and permit refreshing, physiologic rest. Probably 
solanine will act well in those medial states where there is not a very 
clear indication for either. But if the bowel is loaded or the kidneys 
are not ridding the blood of their due proportion of toxins reason calls 
for the treatment of these conditions at once; and here as so often is the 
case, the suffering is nature's effort to direct our attention to conditions 
requiring relief and threatening danger. 

A hot or cold foot-bath will often restore circulatory equilibrium 
and permit sleep. When a man is irritated or worried and wakeful a 
prolonged hot bath has a remarkable soothing effect, somewhat similar 
to that of a cigar. Both act by lowering abnormal vascular tension. 



PARALYSIS AGITANS 707 

Frankly, we know of no indication warranting the use of opiates 
or their ordinary substitutes for insomnia. If the above measures will 
not give restful sleep the case is so serious that a thorough investigation 
is requisite and a radical change in the life, in fact dropping all else in 
the effort to save the reason and the life of the patient. The use of 
opiates leads to the certain drug habit; bromides relieve by drugging 
down into insensibility the protests of nature, and depress the vitality 
when it most needs strengthening. Chloral and its succedanea may 
be indicated as remedies for disease but they are assuredly not remedies 
for insomnia per se. Hyoscine will put the man to sleep and so will a 
knock-out blow on the point of the jaw, but we are not prepared to 
signify our preference. One concession we will make to the votary of 
fashion or business — a glass of hot water at bedtime with seven granules 
of avenine dissolved in it, is quite effective and harmless, the sleep 
being singularly refreshing and the patient awaking with a restful sensa- 
tion. 

PARALYSIS AGITANS 

Shaking palsy or Parkinson's disease occurs at or after 40, from 
heredity, overwork or spinal trauma. The symptoms are paresis, with 
a fine constant tremor, beginning in the hands, face and lips and extend- 
ing over the entire muscular system. It is usually continuous, not 

developed or aggravated by volitional movement, and can be momen- 

* 

tarily checked by an effort of the will. The face is expressionless, 
reflexes increased, cerebration slow and speech slower. Later we see 
dribbling saliva, stooping, with rigid neck, pill-rolling motion of the 
hands and fingers, and the festinating or running gait. The heart is 
weak, palpitation follows slight exertion, there is arteriosclerosis, 
frequently iridoplegia in myosis. At first the tremor is more evident 
in relaxation or after unusual exertion. It may even prevent sleep, but 
eases during sleep. Sensory phenomena are rare except paresthesia, 
or when trophic joint changes develop. Small motions first become 
difficult and then impossible, larger movements later. The face, neck 
and body sometimes flush, with sweating. The sphincters are unaffected. 
The duration is indefinite, death due to intercurrents or gradual decay. 
In many cases no lesions have been found. In others there are con- 
gestiori and dilatation of blood-vessels of the gray matter, atrophy and 
pigmentation of nerve cells, hyperplasia of connective. Dana attributes 
the malady to disease of the central motor neurone. Recovery never 
occurs but the disease may be checked if taken early. Remissions 



708 CHOREA 

are notable. Hereditary cases are less amenable to treatment. Great 
development of tremor roughly corresponds with early paresis. 

Treatment calls for rest, forced nutrition, the best hygienic surround- 
ings and regimen, with careful training of the affected muscles. Tonics, 
warm baths and galvanism are useful. The remedy most successful 
in restraining tremor and securing rest is hyoscine hydrobromate, in 
doses of gr. i-ioo two or three times a day. This may be continued for 
many years without increasing the doses. Cicutine hydrobromate is 
a useful addition. Cannabis and arsenic have been recommended. 
Testicular injections have proved beneficial. Elimination must be 
sedulously maintained. Nuclein and neuro-lecithin should , receive 
trials, and zinc phosphide. It is incredible that in a malady wherein 
spontaneous remissions occur, there should have been no trial of such 
remedies as are directly indicated on strictly scientific grounds. 

CHOREA 

The causes of chorea are uncertain but a connection with rheumatism 
exists in some cases, while the neurotic condition predisposes. Exciting 
causes are mental, moral or physical strain. The strain of an imperfect 
eye may readily cause the disease. It arises also during pregnancy. 
Two-thirds of the cases occur in females, beginning most frequently 
between the seventh and fourteenth year. It is rare in the colored races. 

The earliest symptom is fretfulness and "fidgets," with all sorts of 
movements indicating general discomfort. Irregular jerking movements 
then begin in the arms, face, tongue and legs. These movements are 
irregular in type, the face muscles twisting and working, speech difficult, 
saliva dribbling, the aspect being that of dementia, although the mental 
perception may be hyperacute. The movements grow larger, until the 
child is thrown about so that she can neither walk, sit nor lie quiet in 
bed. In some cases paresis develops, the patient at times being almost 
motionless; in other cases the two elements are mingled. The motion 
ceases during sleep and is decidedly less marked when the child is quiet, 
increasing on physical or mental exertion. It may be confined to one 
side and is frequently worse on one side than the other. Mental devel- 
opment is checked, but rather as a consequence of the disability imposed 
by the disease. In some cases, however, dementia supervenes, or even 
mania. Mitchell divides chorea into five types: ist, those without move- 
ments during rest at some period; 2nd, cases with continued movements 
increased by effort; 3rd, cases where chorea disappears during volitional 
movement; 4th, cases unaltered during volitional movement; 5th, cases 



CHOREA 709 

with alternating types. In bad cases the child may injure himself by 
tossing and sleep may be rendered impossible. Anemia generally 
attends, and the heart is weak and irregular. A systolic mitral murmur 
occurs in three-fourths of the cases. Uncomplicated cases last from four 
to six weeks. Recurrences are common in the spring or fall; but these 
are shorter than the first attack. During convalescence the jerking 
gradually subsides and the paresis may then be more prominent. These 
movements cease last from the face and tongue. The anemia may 
become extreme, the heart fatty, the ankles edematous. The urine is 
deficient in chlorides, with excess of sulphates and phosphates, and the 
presence of indican frequently shows the presence of fecal toxemia 
(Pierce). The knee-jerk is capricious, often weak, always quickly 
exhausted. 

Chorea is to be diagnosed from hysteria, habit-chorea and cerebral 
palsies. Huntington's chorea occurs in adults, with mental diseases, 
and is hereditary. The prognosis is generally good. The course is 
longer if the heart is affected, and in anemics. 

Treatment: — We first seek for the cause. Eye-strain especially 
should be looked for and corrected. Autotoxemia should be obviated, 
by keeping the bowels empty and aseptic. Renal elimination should 
be measured and brought up to the standard. A careful examination 
of the child's entire body, especially including the sexual organs and 
the rectum, should be made, and all possible sources of reflex irritability 
removed. In every case the child should be sent to bed and kept there, 
without books, toys or visitors. In violent cases it may be necessary to 
pad the bed or the child. Hot salt baths with massage should be used 
every day. Anemia calls for iron; feebleness of the heart for cactus, 
and any other general condition present, such as rheumatism, must be 
promptly and effectively treated. Cases presenting excessive violence 
are greatly benefited by glonoin. In other cases the motions are 
restrained and the nervousness soothed by gelseminine, cicutine hydro- 
bromate or solanine, pushed to full dosage. The best hypnotics here 
are hyoscine and cicutine hydrobromates. Arsenic has proved beneficial 
as a heart-tonic and an adjuvant to iron in anemia. Macrotin comes 
near to being a specific as soon as the attack has passed its acme, 
when it should be given up to full toleration. When convalescence 
has well advanced, change of scene is advisable, but excitement of any 
sort must be avoided, as well as hard study and fatiguing exercise. 
These cases do well at the seashore, but are aggravated by any altitude 
above 2,000 feet. Rhythmic exercises in time w r ith music, are of value 
in restoring control over the muscles. 



710 HEREDITARY CHOREA 

HABIT CHOREA 

This disease of childhood may develop primarily or follow simple 
chorea. It is hereditary and may be contracted by imitating another 
choreic. Other causes are eye-strain and similar sources of nerve 
exhaustion. The disease most frequently affects the eyelids, face, neck, 
and shoulders. The movements are spasmodic rather than choreic, 
and are excited by irritations abnormally felt by the patient. The 
movements can be controlled by' the will, are absent during sleep and 
worse when attention is not directed to them. They may be controlled 
by the will more readily than simple chorea. The patient is apt to be 
robust. Speech may be affected. The duration is indefinite, but the 
prognosis is good in choreic cases, or when the source of irritation can 
be found and removed. The treatment consists in finding and removing 
the source of irritation, which may require fitting with glasses, circum- 
cision in either sex, attention to the teeth, the removal of diseased 
tonsils or adenoids, operation for tongue-tie, etc. Effort should be made 
to train the child in controlling these manifestations by his will. The 
use of cicutine hydrobromate or of solanine to lessen hyperesthesia may 
be of value, but these remedies are not to be employed to relieve the 
physician of the trouble of finding and removing the cause of the irrita- 
bility. As in ordinary chorea, calisthenics in classes, with music, aid 
in restoring control. Cold baths of all kinds are of value.. The bowels 
must be kept clear and aseptic, 

HEREDITARY CHOREA 

This malady is more frequent in men, commencing about the 30th 
year, is chronic in its course and tends to mental derangement. 
Heredity is not direct, but is of the neurotic temperament in general. 
The first evidence of the disease is a gradual change in the disposition, 
the patient becoming nervous, irritable, forgetful, perverse and quarrel- 
some. Movements begin in the arms, large; the head and neck becoming 
affected, the legs lastly, with peculiar gait. The patient endeavors to 
slide and push one limb forward, then draws up the other one, which 
is pushed forward in the same manner. Extending to the trunk the 
muscular contractions cause compression of the abdomen and thorax. 
Involvement of the diaphragm causes sudden explosive sounds. With 
the choreic movements the mental symptoms are apparent. Periods of 
depression alternate with mania, and dementia supervenes, the patients 
using a jargon in speech, not due to mechanical disturbances which also 



EPILEPSY 711 

exist. Suicide is frequent. Walking becomes impossible, but the move- 
ments continue except during sleep. They are increased by mental or 
physical effort, but lessen with the approaching dementia. Finally the 
patient is confined to bed, and dies of intercurrent disease, after a 
number of years' course. The diagnosis is made by the age of the patient, 
the mental disorder, and the peculiar gait. The prognosis is usually 
bad. The disease is attributed to congestion of the cerebral cortex, 
with irritation and degeneration of the central motor neurons with areas 
of softening corresponding to the paresis. No treatment has yet proved 
curative, but as applied to the symptoms the patient's condition has 
been ameliorated. 

CONVULSIVE TIC 

In this disease we have large irregular choreic movements of the face 
and neck, sometimes extending to other parts. The neurotic heredity 
is present, while emotional shock is the most common excitant. It 
begins in early childhood, with three sets of symptoms: the move- 
ments described, being extreme contortions of the part affected, increased 
by excitement or exercise; the mental disturbance consisting of fears, 
doubts and morbid impulses. Attempts at motion are frustrated by the 
involuntary retraction of the muscles. The disease passes into chronic 
dementia, with muscular atrophy and death from exhaustion. No 
treatment has proved of avail. The disease usually begins in the eyelids, 
the patient winking or grimacing uncontrollably. Many singular forms 
are described. 

SALTATORY SPASM 

This is a hysteric neurosis occurring in young adults, spreading by 
simulation, characterized by sudden violent jumping or dancing, 
continued until the patient is exhausted and renewed after resting. The 
paroxysms may recur many times in a day, recommencing as soon as 
the patient awakes from sleep. The malady develops when the reason 
is swerved by powerful emotional storm, such as religious revivals. 
The exhaustion is sometimes fatal. The cure is usually suggestive and 
is easy when the operator can obtain control of the patient. 

EPILEPSY 

This is a disease characterized by convulsions with unconsiousness. 
It is a hereditary neurosis, occurring in either sex and earlier in life as 
the neurotic heredity is more marked. Exciting causes are mental 



7i2 EPILEPSY 

shock, traumatism, diseases of the brain, toxemia, reflex irritation and 
circulatory disturbance. It is a feature of a number of diseases of the 
nervous tissues and may be a sequel of such maladies as cerebrospinal 
meningitis. 

Grand mat may be general or partial. Confirmed epileptics show a 
characteristic facies of mental depression and irresolution. The attacks 
may be preceded by headache, giddiness, muscular twitching, mental 
depression or disorder. Sometimes the attack commences with an aura. 
This may be a sense of depression, a cloud dulling the vision, or the sense 
of a globe rising from the stomach to the brain, or of a wave or breeze 
from any part of the body traveling to the brain, the convulsions 
developing when the brain is reached. The aura may be a pain, pares- 
thesia or a disorder of any one of the special senses, or it may be a 
tremor. We have known it to occur with twitching in the muscles of a 
hand, bruised by the handle of an oar in rowing, the twitching visibly 
passing up the nerves of the forearm and arm. Following this we may 
see movements in any part of the body, the patient becoming pale, 
cyanotic and unconscious. 

In petit mat this may constitute the entire paroxysm, or the patient 
may during a period of unconsciousness perform some act, the attack 
lasting but a few seconds. In grand mat the attack may begin with a 
cry, the patient falling unconscious with a general convulsion of tonic 
rigidity, followed by clonic spasms, frothing at the mouth, conjugate 
deviation of the eyes upward and outward to the side most affected, 
and dilated pupils. As the tongue is violently forced out of the mouth 
during the clonic spasm it may be severely bitten during this stage. The 
convulsion ends in rigidity of the muscles of the trunk. The bowels 
and bladder may be emptied. The whole convulsion is over within a 
minute or so, and the patient may be restored to consciousness, although 
he is apt to remain dull for a few moments, or with aphasia, or he may 
sleep for some time. Temporary paralysis may remain, or the patient 
may show decided mental disorder, usually an ugly quarrelsome mania. 
In masked epilepsy substitution phenomena may occur instead of the 
attack, or a state of double consciousness may exist. The attacks 
may follow each other so closely that the periods of unconsciousness 
are merged, and the patient may remain for days or weeks without re- 
gaining consciousness. The muscles may be sore and bruised, or ruptured 
during the convulsion, the bones broken or dislocated. Patients may 
be frightfully burned by falling into the fire. Convulsions at first occur 
at night, or in the early morning, but later occur during the day. The 
convulsions may be absent during intercurrent fevers or pregnancy. 



EPILEPSY 713 

Gowers mentions the following forms of petit trial, arranged as to their 
frequency: Sudden momentary unconsciousness; fainting or sleeping 
without warning; giddiness; jerks or starts of the limbs, trunk or head; 
disturbances of sight; sudden mental disturbance; unilateral peripheral 
sensation or spasm; epigastric sensation; sudden tremor; sensations in 
both hands; pain or other sensation in the head; choking; sudden scream; 
sensation of smell; sensation referred to the heart; sensation referred to 
the nose or eyes; sudden dyspnea and general indescribable sensations. 
After these, automatic actions may be performed. The tendency is for 
the milder forms to merge into the more severe, for the nocturnal attacks 
to gradually become diurnal, and for the convulsions to recur at shorter 
intervals. Leucocytosis exists in both forms. 

Epilepsy must be distinguished from hysteria, which may require 
a careful study. In the latter the pupils are not dilated, the tongue is 
not bitten, nor does the patient hurt or disfigure herself seriously. 
Uremia may be detected by examination of the urine. 

The pathology baffles research. If the patient dies in a convulsion 
the brain shows the effect of the tremendous vascular pressure by 
minute hemorrhages. Other lesions discovered are not characteristic, 
since they occur without epilepsy and it occurs without any of them. 
Haig showed that uric acid completely disappeared from the urine on the 
day before a convulsion occurred. The prognosis is worse the earlier 
in life the malady commences. In some cases mental degeneration is 
rapid; in others the mental development is greater than in ordinary 
individuals. Epilepsies (Jacksonian) limited to one part of the body 
point to a corresponding location in the brain, and the lesion there may 
be removed by surgical intervention. 

Treatment: — The first point in the treatment is to submit every por- 
tion of the patient's body, external and internal, to the most critical 
evamination, that we may detect any possible source of reflex irritability. 
Nothing is too trivial to go unnoticed. It is not necessary that there 
should be the slightest obvious connection between the lesion found 
and the disease. The rule is to treat whatever is found. Eye-strain 
is to be remedied; adherent prepuce removed; the spasmodic sphincter 
dilated; worms removed from the alimentary canal, etc. In epilepsy 
we have to deal with a nervous system morbidly impressible, and with 
an irritation capable of inducing spasms in such a person. Autotoxemia 
may well constitute a cause of such irritability, hence attention to the ali- 
mentary canal is one of our first duties. Epileptics are very often gluttons, 
and the restriction of food to the patient 's needs should follow the cleans- 
ing of the alimentary canal and the removal of intestinal parasites. 



714 EPILEPSY 

All salt should be excluded from the foods, and substituted by sodium 
bromide, in just sufficient quantity to replace the excluded chloride. 
Beyond this the bromides should not be given excepting in occasional 
instances. The writer has succeeded in preventing spasms for many 
months by keeping the patient saturated with potassium bromide, giving 
it up to 600 grains a day, increased or decreased according to the 
patient's sensations. But such cases are not by any means common, 
and in general this remedy is objectionable, since potassium itself is a 
convulsive agent, and in large doses this salt interferes with digestion, 
causes distressing acne, and depresses the vitality markedly, as shown 
by its extinguishing the sexual capacity, though not the appetite. We 
grant that in many epileptics this is a good thing, since they are pas- 
sionate, headstrong and unruly. Nevertheless we cannot but look upon 
the power of a drug to extinguish this function as one which is perilous 
to the patient's vitality. We are not justified in striking so close to the 
vital principle as is signified by such an action, unless the indications 
for such action are clear. 

Solanine fulfills all the functions of the bromides without either of 
the three disadvantages enumerated. It may be substituted for the 
bromides in all instances except as noted, with great advantage. We 
do not advocate solanine as a remedy for epilepsy, but as a remedy which 
will certainly and safely lower hyperreflex excitability, and when that 
constitutes the indication for treatment the remedy may be depended 
upon. Ordinarily the dose should not exceed one grain a day, but it 
may safely be given until its effects are manifest, the first one being 
dryness or irritation of the mouth and throat. 

Valuable adjuvants may be found in the other sedatives, such as 
gelseminine and cicutine hydrobromate, either of which may be pushed 
to full dosage. 

Beyond this the treatment is symptomatic. When we have removed 
all possible sources of reflex irritability, have soothed that irritability 
down to the normal point and have regulated the personal and domestic 
hygiene we have done all for which we have scientific warrant in the 
treatment of epilepsy. In many cases the mental deterioration occurring 
in epileptics is of subjective origin, and would not follow if the patient 
did not know of the epilepsy or did not care. If the heart is feeble 
digitalin may control the disease where other remedies fail. 

Pierce recommends the intestinal antiseptics and colonic flushing 
when examination of the urine indicates the need. The absence of 
uric acid from the urine warns us of an approaching convulsion, but 
as yet the specific treatment that will prevent it has not been developed. 



HYSTERIA 715 

The writer's observations would indicate that veratrine in full doses 
best meets this indication. Since the spasm commences with contraction 
of the cerebral vasomotors, the instant administration of glonoin will 
generally prevent the further development of the convulsion. As the 
effects of glonoin are transitory, however, atropine should be combined 
with it to prolong the effect. The dose is gr. 1-250 of each, and this 
combination has proved so valuable that it has been termed the 
"antiepilepsy" granule; a bad name, since it is not a remedy for epilepsy 
at all but for vasomotor spasm, whether the latter occurs in epilepsy 
or in any other malady. These should be carried about by the patient, 
ready for instant use. 

HYSTERIA 

Hysteria is a functional neurosis, characterized by such a variety 
of phenomena that it has been said that this malady simulates every 
known symptom of every known disease, including death. It is more 
common in women, and that it occurs in those affected with diseases of 
the reproductive apparatus is evidenced by its name. 

Hysteria is one of the less serious inheritances of the neurotic 
constitution. Given an individual whose mental and physical consti- 
tution is considerably below par as to its capability of resisting the 
trials incident to life, add to such a case the influence of bad environment, 
and hysteria results frrom any cause of irritation as a spark sets off a 
powder magazine. In hysteria we find the emotional side of the patient's 
nature highly developed; the control of the will low. The visual field 
is often narrow, with reversals so that red is perceived before blue. 
Various visual disturbances may be present also, or disturbances of any 
of the other special senses. Hysterical points are found by pressure 
over the dorsal, cervical and lumbar spine, over the ovaries and under 
the breasts. Anesthetic areas may also be found, sometimes sharply 
defined hemianesthesia. The hysterical joint is rigid and tender. 
Paresthesias are very common and multifold. Motor symptoms may 
be present of any grade. An exceedingly rapid quivering of the eyelids 
is common in paroxysms. Catalepsy, palpitation, rapid breathing, 
excessive or scanty urine, hematuria, dysmenorrhea and amenorrhea, 
extreme tympanites and rumination are not uncommon. The paroxysms 
consist in violent spells, local or general convulsions, simulating epilepsy 
or tetanus, or multiform attacks. The patient does not injure or 
disfigure herself seriously. She is perfectly conscious and able to control 
the manifestations if she chooses. 



716 TRAUMATIC HYSTERIA. 

The diagnosis is sometimes difficult, in fact it is easier to recognize 
the hysteric condition than it is to describe it. However, the diagnosis 
should not stop with the determination of hysteria. We have known 
convulsions to be diagnosed as hysteric in a patient unquestionably 
hysterical, yet the convulsions were caused by a pelvic abscess and 
promptly ceased when the abscess was evacuated. The diagnosis must 
therefore ascertain why the patient is hysterical. The cause may be 
strictly physical, as in the case just cited, and in others where health 
was restored by ridding the patient of intestinal worms, or of an 
adherent prepuce, or of an anal fissure. It is incredible to those who 
have not studied the matter, how an apparently trivial disorder may 
cause such a leakage of nerve force, already far below par, as to induce 
the most formidable phenomena. The removal of a corn has often 
restored peace to a perturbed mind. 

But the causes of hysteria are not to be found alone in the physical 
realm. Quite frequently these overindulged, capricious creatures go off 
into a spasm to revenge themselves for some slight disappointment. 
Many cases can only be comprehended when the sexual relations have 
been investigated, and here the physician not seldom meets with condi- 
tions which can only be met by quietly taking his departure and sug- 
gesting the employment of another adviser. 

The neurotic instability may be lessened by attention to the personal 
and domestic hygiene, by keeping the digestion in good order, prescribing 
a light but nutritious diet, with quiet, absence of unwholesome excite- 
ment, with pleasant surroundings and diversions, and occupations suited 
to the mental and physical capacities of the individual. The paroxysms 
may be easily broken by a hypodermic injection of apomorphine. 

The further treatment depends on the conditions. The removal 
of autotoxemia does wonders. Gelseminine subdues erotic sensibility; 
cicutine hydrobromate seems to be a specific in relieving that mental 
condition which leads the friends to fear the approach of insanity, while 
the dread of insanity or other approaching evil subsides under the use 
of anemonin. Any of the valerianates restores self-control when lost 
through grief or other overpowering emotion. These remarks may 
appear fanciful or absurd to him who knows only mechanical or 
material therapeutics. The writer speaks, however, from long experience. 

TRAUMATIC HYSTERIA 

This title has been assigned to cases of hysteria following injury. 
It is otherwise called " railway spine." There is a wide variation in 



WRITER'S CRAMP 717 

the opinions of those who treat of this disease. A distinguished railway 
surgeon was so skeptical in regard to such cases that he was pointedly 
asked whether he believed there were any circumstances under which 
a railroad could possibly be in the wrong, or responsible for injuring its 
victims. There is no question but that great imposition has been 
practised upon corporations by seekers for damages, but this does not 
indicate that injury is impossible, even if no evidences can be elicited 
by physical examination. 

The symptoms follow injury received while traveling. The patient 
believes or pretends that he is injured, although no evidences can be 
elicited by examination; or there may be subacute inflammation, hem- 
orrhage or degeneration of the spinal cord. The patient generally 
complains of stiffness in the back, with points of exquisite tenderness, 
elicited by superficial pressure. He becomes irritable and tires quickly, 
suffering with palpitation, bradycardia or tachycardia, showing wide- 
spread irritability of the sympathetic nerve. Other vasomotor changes 
are sweating, coldness and flushing, but not cyanosis. Functional disorder 
of any other organ may be present. The deep reflexes are exaggerated, 
but ankle clonus is not present. The muscles are flabby but not wasted 
and the reaction of degeneration is absent. If organic disease is present 
it affords its own signs. The tenderness, increased by movement, may 
indicate inflammation of the muscle. Deeper tenderness may signify 
separation of the spinous processes or injury of the intervertebral liga- 
ments, causing great pain when the patient drops his weight upon his 
heels. The pain may prevent sleep. In severer cases the spinal disease 
may be unquestionable. The diagnosis can only be made out by the 
most careful repeated skilled examinations. The prognosis is doubtful. 

The treatment consists in rest, a carefully arranged regime, counter- 
irritation over the spine and such symptomatic measures as may be 
indicated. The nervous sedatives, gelseminine, solanine, cicutine and 
hyoscine hydrobromates, are of immense value. 

WRITER'S CRAMP 

When persons whose occupation, like the writer's, involves the per- 
sistent use of a certain group of muscles for long daily periods, continued 
through years, there is apt to occur in the course of time a certain singular 
disability which interferes with the performance of that particular set 
of associated movements. If the muscular exertion is severe, as in the 
case of brakemen, the malady will come much sooner. In these cases 
there is probably a subacute inflammation of the muscular tissues. In 



718 TETANY 

other cases a certain degree of neuritis is present, with anesthesia of the 
affected areas. In still other cases the vasomotor nerves are irritated, 
giving rise to paresthesia of the affected parts. In either class the same 
muscles may be employed with impunity, in movements requiring other 
combinations, but when the patient attempts to perform the old task the 
muscles become spasmodically contracted. 

The prognosis is not very good. Patients thus disabled from writing 
with the right hand may learn to write with the left, but the disease re- 
curs more quickly. 

The musculonervous degeneration may be remedied by mildly fara- 
dizing the affected parts and by gentle massage with hot cod-liver oil. 
The digestion should be regulated also. In the vasomotor conditions 
veratrine will relax spasm and at the same time stimulate the muscular 
fiber to better nutritive conditions. In general, however, the occupation 
should be changed as radically as possible. 

ADIPOSIS DOLOROSA 

Dercum describes this as a disease of adults with fat deposited over 
the body in bunches, later becoming general, with pain, anesthesia and 
great debility. It is not myxedema. There are no mental symptoms. 
The disease is attributed- to degeneration of the peripheral nerves. It 
lasts for many years, the patient dying of debility or fatty heart. 

TETANY 

The cause is unknown, no lesions of the motor tract having been de- 
tected. It has occurred in epidemics, probably imitative. It occurs with 
gastrointestinal maladies, during pregnancy and lactation, with myxedema 
and cachexia strumipriva, after exposure to cold, and was noted by the 
writer during a case of chronic Addison's disease. Males are more liable 
in childhood, females in adult life. Tailors and shoemakers are specially 
liable. The symptoms consist in tingling, formication, pain or numbness 
for some days, in the arms, symmetrical, followed by stiffness beginning 
in the hands and extending to the elbows, the fingers clenched, pain se- 
vere, the muscles hard. It may extend to the legs. Edema and sweat- 
ing may attend. This may pass off in a few minutes, last for hours, or 
until sleep. Attacks occur mostly at night, and are excited by emotion. 
There may be severe head and back ache. In the intervals Trousseau's 
sign may be developed — attacks may be induced by prolonged pressure 
on the main nerve trunk or vessels of the affected limbs. Chvostek's 



INFANTILE CONVULSIONS 719 

sign is a peculiar excitability of the facial muscles, spasms being produced 
if their trunks are lightly percussed with a hammer, or lightly stroked. 
Erb's sign is the greatly increased electric excitability of the muscles and 
occasionally an alteration of the electric reaction. Hoffmann's sign is 
an increased reaction of the sensory nerves to electric stimuli. The face, 
hands and feet may be swollen slightly. Hysteric stigmata may be pres- 
ent, also anesthetic areas, tender points of the spine, herpetic clusters, 
falling of the hair, painless ulcers, contractures of neck, back, diaphragm, 
larynx, urethra, etc. Slight fever may accompany the paroxysm. The 
urine contains phosphates and the autotoxemia is shown by indican. 
The diagnosis is easy. The disease tends to spontaneous cure. The 
treatment looks to the causes and the general conditions. The spasm 
gives way promptly to a whiff of bromide of ethyl, and in a case of the 
writer's the lady carried a vial in her pocket and found the relief so sure 
that finally when she felt a paroxysm coming she would feel for the ethyl 
and if it was there the spasm at once subsided. This sufficiently indi- 
cates the neurotic nature of the case. The digestion always needs regu- 
lation, and genitourinary affections should be treated. 

INFANTILE CONVULSIONS 

The causes of children's convulsions are, organic cerebral lesions, 
the neurotic temperament, emotional stress and storm, rickets, acute 
infections, serous inflammations, renal maladies, peripheral irritations, 
and debility especially resultant from gastrointestinal disease. Among 
the peripheral irritations those of the bowels and stomach are most im- 
portant, probably outnumbering all the rest of the above list. Intes- 
tinal worms are sometimes the cause. More frequently indigestible food 
or fecal collections cause "fits." The convulsion begins with twitching 
of some muscles or deviation of the eyes and staring, local or general 
rigidity, gnashing of the teeth, or trismus, tetanic contractions of the ex- 
tremities, the flexors especially, opisthotonos or respiratory cramp, the 
abdomen of boardlike hardness, the spasms tending to become clonic 
before they cease. Cyanosis develops from the respiratory cramp. F«am 
appears at the mouth with blood if the tongue has been bitten. The 
urine and feces may pass. A cry or screaming may inaugurate the spasm. 
The paroxysm passes off in a few moments, leaving the child drowsy, 
sleeping or irritable. The attacks may recur rapidly, especially when 
due to unwholesome food in the stomach. The diagnosis is as to the 
cause. Gastric convulsions leave the child relaxed. The presence of 
fever is significant. The prognosis depends on the diagnosis. 



720 NEURASTHENIA 

Spasms may be speedily quelled by chloroform inhalation. Empty 
the stomach at once, and the diagnosis and cure occur simultaneously. 
Fever calls for cold to the head. Calomel followed by salines is usually 
effective. The gums may need attention. Repeated convulsions re- 
quire a study of the cause and its removal, and quelling the hyperexci- 
tability by the use of cicutine and solanine. We find it impossible to 
specify more closely, since the conditions are so various. 

NEURASTHENIA 

Neurasthenia is a state of Continuous exhaustion and abnormal ner- 
vous impressibility. It resembles fatigue of body but is far more com- 
plicated. Neurasthenia destroys the balance between waste and repair. 
It consists essentially in fatigue of the central nervous system, checking 
its inhibitory influence over the various organs and structures, re- 
sulting in their increased activity and early exhaustion. The neurotic 
heredity is marked, and this may be developed by improper mental and 
physical training during childhood and adolescence. Persistent mental 
work without sufficient rest and recreation, especially when conjoined 
to sexual and other excesses, and the powers have been sustained by stim- 
ulants, are the usual antecedents. While frequent among the wealthy 
brain workers it is not unknown among poor laborers, in country or 
town. The society woman is especially prone to it — the degree of in- 
telligence that drives a woman into the social struggle without the brains 
to enable her to take proper care of her health, might perhaps be ranked 
as a subhead under the general classification of imbecility. Neurasthenia 
occurs most frequently between 20 and 50, in single men. and married 
women, in the highly developed races, such as Americans and Jews. 

Exciting causes are trauma, anemia, toxemia, prolonged mental strain, 
overwork, excessive emotion, syphilis, gout, influenza, depression from 
misfortune or grief, excess in tobacco or alcohol, crises of puberty, mar- 
riage, the menopause, sexual excess, disappointed love, and quite frequently, 
sexual starvation rather than excess when the latter is normally indulged. 
"Autotoxemia, from whatever source, is in my opinion the most frequent 
cause of neurasthenia. "(Geo. F. Butler.) 

Charcot considers headache, backache, gastrointestinal atony, neuro- 
muscular weakness, cerebral depression, mental irritability and insomnia 
the fundamental symptoms of this disorder, the true stigmata of the neu- 
rosis. Motor disorders are muscular weakness and quick fatigue, trem- 
bling and twitching. Tenderness may be found over the spinous processes. 
Severe persistent pains occur, not along nerves, not increased by pressure 



NEURASTHENIA 721 

or amenable to antineuralgic treatment, wandering from place to place. 
Seats of election are the knee, elbow, ankle, wrist, calf, forearm, phalan- 
ges, with supraorbital neuralgia. Dyspnea may be caused by thoracic 
pain. Pressure in the head is frequently complained of. 

Visual disturbances are common — photophobia, disorders of hearing, 
smell and taste, hyperesthetic mostly. Gastrointestinal disorders are 
almost invariable, nervous indigestion, atony, anorexia, flatulence, heart- 
burn, palpitation and epigastric distress, etc. Anemia of the brain is 
common, with fainting an hour after meals, with hunger. Pancreatic 
digestion is especially defective. Hyperacidity from lactic fermentation 
is usual. Bile is also deficient. The heart is weak and palpitates, the pulse 
feeble and rapid, the feet cold, vasomotor equilibrium easily disturbed. 
Sexual power is weakened, more in the male. The mind is weakened 
and the effort of thought irksome, the temper irritable. The memory 
for details is poor. Even when the patient sleeps he awakes 
unrefreshed. 

Atmospheric changes are acutely felt and arouse various symptoms. 
The pulse falls when the patient bends forward, for a brief time(Erben). 
Polyuria with increased elimination of urea and phosphates is common. 
The acids are increased and free lactic acid, indican, indol and skatol 
are present(Vigouroux). Many neurotic manifestations have been re- 
corded, any of which may not be present in any particular case. 

Remissions are usual throughout the course. The depression periods 
become less severe and frequent as the patient improves. Selfishness 
and hypochondria are apt to develop. 

The diagnosis is from hysteria, dementia paralytica, cerebral syphi- 
lis, multiple neuritis, neuralgia, migraine, melancholia, idiocy, paranoia, 
organic gastrointestinal disease, cardiac disease and tuberculosis. Most 
of these may be associated with neurasthenia at some period in its course. 
The treatment is conducted along the lines laid down for neural malodies 
in general. Neurasthenics are quickly exhausted as to irritability, and 
their medicines should be given in minimal dosage with periods of absti- 
nence. All habit drugs should be avoided. Sleep should be sought 
from vasomotor readjustors and never from hypnotics. The "nervines" 
are very useful, such as passiflora, cypripedin and scutellarin. Not 
one of the tonics can be borne in full doses and strychnine is par- 
ticularly dangerous. 

Bearing in mind always that the particular neurosis under consider- 
ation is largely, often chiefly, psychologic, it is impossible to overestimate 
the reflex importance of rest in its salutary action upon the mind. Perfect 
relief from bodily fatigue works wonders in effecting general amelior- 



722 NEURASTHENIA 

ation, though in many cases gentle and well regulated exercise is of un- 
questionable value, especially in certain states and in certain stages of 
recovery. Released from the wearing anxieties which have finally re- 
sulted in neurasthenic conditions, the mental faculties gradually but surely 
regain their normal strength and elasticity, particularly if the environ- 
ment is such as to inspire reawakening hope and confidence. 

A new life appears to accompany the results of carefully studied and 
judicious treatment, and in compulsory yet grateful repose the. patient 
soon finds that his thoughts are brighter and more cheerful, his capacity 
for mental enjoyment keener, and his physique markedly improved under 
the influence of the general recuperation. Sleep and healthy digestion, 
which have perhaps long been strangers to him, assume a natural phase; 
troubles which but lately oppressed the mind with persistent anxiety 
appear purely imaginary, or at least are deprived of their baneful effect, 
while the entire system responds favorably to the new regimen and watch- 
ful care. The records of this treatment abound in illustrations of its benefi- 
cent agency in the recovery of normal conditions. It is emphasized 
strongly here as of unique paramount importance, in which experience 
leads us to place almost implicit faith. 

Hydrotherapy is an invaluable ally in dealing with neurasthenia. 
It has been asserted that there is probably no chronic disease in which 
its application contributes more largely to the betterment of the patient's 
condition and which renders the effect of changed environment, removal 
of etiologic factors, diet, electricity and medication, more pronounced 
and enduring. 

Eminent writers have endorsed the value of hydrotherapy and balneo- 
therapy in neurasthenia. Jolly recommends the imbibition of large 
quantities of water as an aid to renal and peristaltic action, its external 
application being valuable in those cases in which increased excita- 
bility is combined with tendency to exhaustion. One can hardly 
overestimate the efficiency of cold rubs, half and full baths, with 
friction, douches, sprays, etc., in their favorable influence upon the 
cutaneous tissues and upon the circulation and tone of the vessels. Krafft- 
Ebing asserts that "in the management of neurasthenia the water treat- 
ment is of the greatest value, because as applied preferably in institutions, 
it admits of all possible excitant, calming and alterative effects upon the 
diseased organism and its tissue change." He considers hydrotherapy 
important in reducing insomnia, and in pronounced neurasthenia regards 
it as a valuable aid in regulating cardiac activity, dilating the peripheral 
vessels and increasing or diminishing (as desirable) the cerebral circu- 
lation. 



NEURASTHENIA 723 

Various hydriatic measures may be adopted, all of them more or less 
efficacious, according to the conditions in which they are applied. Klem- 
perer is authority for the assertion, amply corroborated by experience, 
that "in hydrotherapeutic efforts we observe quite an extraordinary and 
incomparable stimulation of the nervous system, which is reflected upon 
the various organs. " Dr. William N. Draper, speaking of this procedure, 
remarks: "It seems to be more effective than any treatment by medicine 
in stimulating the nerve centers, in restoring the equilibrium of the cir- 
culation and reviving the activity of the organic functions," adding for- 
cibly that "its best results require the appurtenances of a well-ordered 
establishment, where all the various methods of applying water can be 
wisely and skillfully directed." 

Many like testimonials might be adduced to show that in the water 
treatment a veritable means of restoration resides. "Who can calcu- 
late", says Dr. Frederick Peterson, "to what degree we may thus influ- 
ence the biochemical processes of the body, the metabolism of tissues, 
the carrying off of degenerated and toxic substances, or determine how 
much we may affect the vascular neuroses, the local anemias and hyper- 
emias of the brain and spinal cord?" 

With regard to electricity, especially the static form, its use is gener- 
ally conceded to the treatment of local neurasthenic symptoms — such 
as morbid cephalic sensations, extreme intestinal atony, weakness of 
the sexual organs, etc. In these conditions both faradism and galvan- 
ism, combined or alternated, have proved beneficial. Much depends 
upon the competent application of this subtle force — so far as experi- 
ment has shown its curative property in certain cases seems undeniable, 
while as a therapeutic agent in obstinate neuroses it is inferior to rest 
and hydrotherapy. 

One of the commonest and most disastrous prescriptions given to 
the neurasthenic is, as Bremer remarks: "Take plenty of fresh air 
and exercise." The "fresh" part of the injunction is all right (in some 
sanitariums such patients are often compelled to be in the open air all 
day, even though in bed, and when too weak to move about or sit up), 
but the prescription of "exercise" is all wrong. There is a widespread 
delusion that exercise is beneficial under all circumstances. The acme 
is reached when the gymnasium and athletics are recommended to all 
neurasthenics. Many athletes and prize fighters become neurasthenics 
by dint of too much muscular exercise. Even in laboring men who have 
heavy work to perform, nervous prostration often results. Whenever 
and as often as a muscle is contracted, certain brain cells enter into 
activity. The brain in one or more of its parts is, in neurasthenics, 



724 NEURASTHENIA 

easiest irritated and exhausted. Owing to the close functional depend- 
ence and interdependence of all parts of the brain, work of the motor 
region governing muscle contraction during exercise must redound on 
other weakened and easily irritable parts. Some cerebrasthenics whose 
slightest mental effort is followed by brain-fag can walk long distances 
without feeling any fatigue, but this is often an expression of over-fatigue. 

Dietetics are also badly abused. Neurasthenics are often advised 
to eat plenty of nourishing food; and gorge themselves without consid- 
ering that, as Brewer remarks, it is not the amount of nutriment, even 
when properly digested and absorbed, which determines nutrition, but 
the use to which the digested food can be put in the tissues. The arti- 
ficial foods have the effect of weakening the stomach by rendering it, 
so to speak, apathetic, thus interfering with the churning of the food 
and the secretion of gastric juice. An ounce of butter and bread digested 
naturally outweighs a pound of beef incorporated in the system under 
artificial conditions. Beef extracts are especially objectionable in neuras- 
thenics. Milk and fresh fruit often disagree with these patients. Dietetics, 
therefore, should be a matter of individual prescription, rather than 
any unvarying directions. Excess of the proteids and excess of the 
starches and sugars are equally to be avoided as the two excesses acting 
in a vicious circle aggravate each other. Starchy food fermenting in 
the intestine causes absorption of proteid products of decomposition. 

The general principles of treatment consist in educating the patient 
to live within his nerve income, which is small. The man of average 
strength cannot with impunity attempt to perform the muscular feats 
of an athlete or prize fighter. Likewise, the neurasthenic cannot do 
what many of his acquaintances do. He must forego a great many 
pleasures; abstain from many pastimes and entertainments; refrain from 
many articles of food which to him seem simple, natural and health- 
ful, but nevertheless, stand in the way of his recovery. He must above 
all learn his limits. His treatment must be a sort of education, teach- 
ing him to be patient and temperate in all things. He must learn to 
adapt himself to his surroundings, to reestablish the lost normal equilib- 
rium between him as an individual and his environment. To miti- 
gate is now to prevent the collapse which constitutes such a discouraging 
feature in the course and progress of neurasthenia, discouraging 
alike to patient and the family. 

To achieve this end the patient must be taught to avoid extremes, 
especially of emotion and work, mental or physical; in short, bodily and 
mental hygiene adapted to his individuality must be instituted. No 
rest-cure, no sea-side, gymnastics, cold or warm water; in fact, no par- 



ANGIONEUROTIC EDEMA 725 

ticular method is equally applicable to all cases; and drugs alone will 
not bring about restoration to health. 

During the whole course of the treatment the patient should be 
under the control of a physician and during treatment should be 
severed from the environment in which the disorder has grown up. He 
should receive only the diet, hydrotherapy, balneotherapy and drug 
treatment indicated in his particular case. The great results formerly 
attained at watering places were due to the partial application of these 
principles and to the medical control exercised. No rest cure is prop- 
erly carried out where these principles are neglected. Rest cures under 
lay control, whether of trained nurses or otherwise, are simply quackish 
lounging places. That the training of a widely advertised system 
of rest cure is eminently deficient, is shown in the fact that nurses 
trained under this system never detected the untoward actions of drugs 
used in treatment until decades after their existence had been pointed 
out by neurologists. 

In conclusion it may be stated in general terms that the malady 
now recognized as neurasthenia, complex as are its various manifes- 
tations and often obscure its etiology, is more amenable to successful 
treatment than is commonly supposed. We have indicated the promi- 
nent features to be considered, together with the means of alleviation 
and cure proved by actual test to be most efficient. No victim of the 
wide-spread malady should despair, or imagine that his case, however 
aggravated, may not yield to intelligent care and the employment of 
methods whose records augur the happiest results. 

V. VASOMOTOR AND TROPHIC 
DISORDERS 

ANGIONEUROTIC EDEMA 

This malady is also known as Quincke's disease, giant urticaria, 
and by at least six other titles. It is characterized by one or more 
acute circumscribed edemas in localities containing loose webs of con- 
nective, such as the eyelids, ear lobes, lips, prepuce, neck and wrists. 

There may be a period of general malaise or digestive disturbance, 
or the attack may be unheralded. The swelling develops within a 
very few moments, rarely occupying some hours. It is apt to be sharply 
defined, quite large, attacking but one locality as a rule. The skin 
may be pale or congested. It does not readily pit on pressure. The 
regions affected in Collins' 71 cases were, the face 29, extremities 22, 
trunk 6, larynx 5, genitals 3, stomach 3, palate, neck and mastoid 1 each* 



726 RAYNAUD'S DISEASE 

The swelling may subside as quickly, or in a few hours, or not for 
some days. Others may appear and prolong the duration. Periodic 
recurrences are common, at the same or other points. Stiffness, burn- 
ing, itching or numbness may attend, or ordinary urticaria may coexist. 

There is no special implication of sex or age. The malady is heredi- 
tary. Digestive disturbances excite attacks. It replaced malaria for 
a patient of Matas. Traumatisms and exposure to drafts seem to have 
induced attacks but the dependence of the malady on intestinal toxemia 
seems clear. As with ordinary urticaria, overheating and stimulant 
beverages excite attacks. Wende found in his cases albuminuria and 
hemoglobinuria. 

The disease is a local vasomotor neurosis, the exciting cause acting 
on the nervous centers. Lodor attributes it to a rapid rise of lymph 
pressure in areas of low resistance, causing sudden and rapid vasomotor 
paralysis there. 

The diagnosis is made by the sudden development, absence of pit- 
ting, quick subsidence, heredity, liability to urticaria, and presence of 
toxemia. The malady is annoying but not dangerous unless it attacks 
the glottis. Recurrence will depend much on the recognition of the 
exciting cause and the patient's willingness to avoid it. 

The bowels should be cleaned by a mild cholagog such as euony- 
min, gr. i to 5, followed by saline laxatives, and quickly disinfected by 
sodium sulphocarbolate, about two scruples a day. Renal elimina- 
tion must be sustained. Generally an evening dose of veratrine, gr. 
3-134, well diluted, will be of great benefit. A sweat by pilocarpine 
quickly gives relief if the itching is intense. Copper arsenite in small 
doses, gr. 1-250 every 2 hours, is useful if there is acidity or jaundice. 
The patient must avoid the foods that excite attacks and keep his bowels 
free and aseptic. 

Intermittent dropsical effusions into the joints have been described, 
the knee being most frequently affected. The cause and pathology 
are conjectural as yet, but as it occurs in neurotics it is attributed to 
nervous perturbations. The affected joint suddenly swells, without 
other evidences of inflammation, and in three to eight days subsides. 
Recurrences at regular intervals of one to four weeks may continue for 
years. The prognosis is doubtful, the malady being obstinate. There 
has been no distinctively beneficial treatment as yet fitted to the disease. 

RAYNAUD'S DISEASE 

This designates a persistent vasomotor spasm affecting the extrem- 
ities symmetrically. It is probably centric but no such lesions have been 



RAYNAUD'S DISEASE 727 

detected as the symptoms would indicate. Peripheral neuritis and 
endarteritis have been found in some cases. It is a disease of women 
and children rather than of men. The neurotic state generally under- 
lies it. The malady is aggravated by cold. 

The anemic stage presents local spasm of the vessels of a finger, or 
several, which become white or livid, cold, firm, dry or moist, and 
anesthetic. After a time, depending largely on the temperature to 
which the affected parts are exposed, this subsides, leaving a sense of 
tingling like that of parts that have been frosted and are thawing. In 
the stage of asphyxia the parts are cyanotic and swollen, with venous 
congestion. This may affect the ears, nose and toes, and is more liable 
to recur than the preceding, on slight provocation. It recurs also in the 
the same parts. Hemoglobinuria often accompanies this form, espe- 
cially in children. In other cases there is an excess of urates. Evi- 
dences of these attacks remain in transverse ridges on the nail at the 
point that was in the matrix at the time. But when the spasm endures 
too long and is sufficient to choke off the nutrient blood, gangrene results. 
Black spots or vesicles appear about the end of the finger, and slough 
off leaving a sluggish ulcer. In severe cases the terminal phalanges 
or other affected parts may be lost. Such cases affect other parts also, 
such as the breasts, where small patches of the skin die. The severer 
forms are accompanied by pains similar to those of senile gangrene — 
or a shoe too tight at the instep. Sometimes glycosuria accompanies, 
but this complicates the diagnosis. 

"A neurosis characterized by enormous exaggeration of the excito- 
motor energy of the gray parts of the spinal cord that control the vaso- 
motor innervation," was Raynaud's definition. Later writers insist on 
gangrene as justifying a diagnosis, slight and superficial, as well as sym- 
metric. Syringomyelia, leprosy, diabetes and hysteria are to be 
excluded. 

The prognosis is good, except in marasmic children. The paroxysms 
tend to cease in time. The treatment of the paroxysms consists in the 
application of heat, with vasomotor relaxants, such as glonoin, and 
atropine to restore warmth to the surface. Massage with various forms 
of electricity have been lauded. A full dose of pilocarpine has given 
prompt relief. This is especially advisable when the pains indicate 
strangulation and approaching gangrene. During the intervals any 
derangement found in the general health should receive attention, the 
digestion especially; the affected parts should be protected against cold, 
and given abundance of non-fatiguing exercise. The continuous influ- 
ence of atropine has proved of great value in the writer's cases. The 



728 DIFFUSE SCLERODERMA 

vasomotor condition present in late pregnancy being exactly opposed 
to that in this malady, the writer has advised marriage and pregnancy 
in two cases of Raynaud's disease, and the result has in both cases jus- 
tified the advice. To sustain vasomotor relaxation veratrine would 
seem to be the remedy indicated, but in every case that has come to the 
writer there has been a feebleness of pulse that contraindicated full 
depressive doses. Possibly the less powerful relaxants, gelseminine or 
cicutine hydrobromate, would meet the need; in fact, in one case the 
latter proved of unmistakable benefit. 

FACIAL HEMIATROPHY, PROGRESSIVE 

Quite rarely cases have been observed in which half the face is 
atrophied, the process stopping at the exact middle line. Skin, muscles 
and bone may be involved. Chronic interstitial trifacial neuritis has been 
found in some cases, disease of the Gasserian ganglion in others, while 
inflammations of the cervical sympathetic and of the trigeminus have 
been observed in others. The fat is absorbed, the skin atrophies, pig- 
ment is often deposited, and the vessels are enlarged. 

The cause is unknown. The disease commences early in life, compli- 
cating other neurotic manifestations. It has been observed with 
neuralgias, migraines, epilepsy, mental disorders, convulsive tic and 
chorea if the latter affects the jaw and tongue; and with ataxia and 
multiple sclerosis. It has followed traumatisms and acute infections. 
Cases are more severe the earlier in life they begin. 

The skin flattens on the affected side, if progressive the muscles and 
bones are involved, white or pigmented areas appear, depressed, along 
the courses of nerve trunks; the hair becomes thin, dry and scanty, the 
sebum scanty and the skin dry. Flushing and dilatation of the pupil 
are rarer. The non-a trophic side alone reddens when blushing occurs. 
Sensation is not affected as a rule but sometimes electric and tactile sense 
is lessened. Taste is not affected even if the tongue is atrophied. 

The only affection mistakable for this is congenital asymmetry, and 
here the skin is not perceptibly altered in texture or secretion. 

The prognosis is bad as to cure, but the malady does not affect lon- 
gevity. No satisfactory treatment has yet been devised. 

Facial hemihypertrophy is very rare; congenital, the soft parts are 
enlarged; secretion increased; no etiology, pathology or treatment known. 

DIFFUSE SCLERODERMA 

A circumscribed or symmetric induration of the skin, in spots, 
streaks, bands or patches, often accompanied by telangiectases. 



DIFFUSE SCLERODERMA 729 

The symmetric form develops slowly or acutely, with rheumatoid 
prodromes, or paresthesia, muscular cramps or neuric sensations. 
Vesicles, blebs, scales, local sweating or anesthesia may precede the 
induration. This affects the upper parts of the body chiefly, as an indu- 
ration or firm edema, only at first pitting. The skin is tense, shining, 
smooth, waxy, or dirty-yellowish. The limits are ill-defined. It may 
rapidly or slowly involve much of the skin; the face is a mask, the lips 
open with difficulty, the eyelids are less affected, and respiration may 
be impeded. The abdomen is not often affected. At times the course 
is so slow that years may be occupied in covering the body. The patient 
may be quite helpless. There may also appear subcutaneous tubercles, 
eczema, erysipelas, canities, anidrosis, zoster or acne. The mouth and 
vulva may be alone affected. G. F. Butler saw a woman whose entire 
face, chest and breasts were affected. 

In the later stages the affected areas become indurated and con- 
tracted, the skin is thin and tightly drawm, dry, scaly, fissured or ulcer- 
ated, facial wrinkles disappear, the muscles atrophy, teeth fall, contrac- 
tures form, and various pains and other symptoms of degeneration occur. 
Gastrointestinal ailments cause marasmus, or the case ends with renal, 
cardiac or pulmonary intercurrents. 

Pigmentary changes are common, some patches dark and others 
white. Forcible movement of affected parts causes pain, and the skin 
gives way. The surface is cool, and very sensitive to cold. In time 
the bones atrophy, or exostoses form. 

While there is some faint resemblance to Addison's disease, and to 
Raynaud's, diagnosis is easy. The prognosis is doubtful but some have 
recovered. 

Morphcea or circumscribed scleroderma occurs in small areas corre- 
sponding to the distribution of nerves; firm, smooth patches, points, 
lines or bands, slightly elevated or depressed, surrounded by a delicate 
violaceous halo, followed by atrophy. The halo precedes the induration, 
which develops in the center of the patch, and assumes the hue of old 
ivory. The patch is rarely larger than a dinner plate. Later the skin 
atrophies. The patch may he dotted w T ith pigment or open mouths of 
sebaceous follicles. Few subjective symptoms are present — sometimes 
itching or other paresthesia. The spots may be pigmented or show a 
netting of fine dilated capillaries. 

Tension may be relieved by moist heat and massage. The general 
principles of hygiene and drug treatment are applicable. As a remedy 
that has proved of value in other instances where centric nervous disease 
has had cutaneous manifestations, zinc phosphide deserves a full trial. 



730 ACROPARESTHESIA. 

AINHUM 

This malady affects the toes, especially the little ones, of dark skinned 
races. A narrow groove appears on the inner plantar surface on one or 
both feet, and gradually encircles the toe. As it deepens the toe swells, 
but with little pain. It may take years for the toe to be thus amputated. 
All the toes may thus be shed. The disease affects men, rarely women 
or children. The tissues of the affected toe degenerate, the bone being 
absorbed. The cause is unknown. Heredity has been affirmed. 
Manson thinks it begins with a wound and is kept up by constant 
irritation. 

No treatment has been devised excepting amputation of the toe. 

The malady prevails in India, Syria, the west coast of Africa, Brazil, 
and possibly other parts of the tropics. 

ERYTHROMELALGIA 

Weir Mitchell described this disease as characterized by paresthesia, 
redness and pain, usually in the toes and heels, with general disturbance. 
While arteriosclerosis in the affected limbs has been detected the disease 
seems due to vasomotor disturbance. Cold excites it, rheumatism and 
the neurotic state predisposing. Young men are most frequently the 
victims. 

Pains begin in the feet, with redness and swelling, the tenderness 
preventing walking. Headache, dizziness and syncope with palpitation 
may attend. It is most frequent in summer and is aggravated by heat 
and by standing. Diagnosis is not easy as it resembles inflammation. 
Hemiplegia or organic spinal disease may be present. The prognosis 
is good but recurrences are frequent. 

The attack may be at once cut short by plunging the feet into cold 
water. Massage, faradism, galvanism, hydrotherapy, and measures to 
improve the general health and the nervous resistance, are appropriate. 
Care should be taken to see that the feet are properly shod. Many a 
corn has been treated as a serious or general malady. 

ACROPARESTHESIA 

A disease displaying abnormal sensations in the hands, slight 
vasomotor disturbances, and slight stiffness of the ringers. It sometimes 
follows injury, or such exposure to cold and wet as laundresses endure. 
It affects mostly grown women. 



TREATMENT OF NEUROSES 731 

Formication and tingling or numbness affect the fingers of one or 
both hands, developing suddenly. The toes are sometimes affected. 
The pain is worse at night and in early morning, and on exposure to 
heat. The parts may be cyanotic and cold, or pink and warm; hyper- 
esthetic or anesthetic; or stiffened. Slight trophic changes may follow. 
The attacks last a few minutes, or hours, recur frequently or at long 
intervals. The tender toes following typhoid may be a form of this 
malady. 

Diagnosis is easy; distinguishing ataxy, tetany, hysteria and Ray- 
naud's disease. The prognosis is good. Alkaline lotions quickly 
relieve the tender toes, and possibly the fingers. Change of occupation 
is advisable for laundresses. Faradism, with such remedies as the 
general condition warrants and tonics are recommended. The digestion 
should be regulated. 

MERALGIA PARESTHETICA 

Bernhardt 's disturbance of sensation consists of paresthesia and 
abnormal sensation on the outer aspect of the thigh, in the area supplied 
by the external cutaneous femoral nerve. Chronic interstitial neuritis 
is sometimes present. The malady has been attributed to injury, over- 
exertion, infections; predisposing causes are found in alcoholism, consti- 
pation and pregnancy; cold douches seem to have aroused it; heredity 
is claimed. 

We may find burning, tingling or stabbing pains, a sense of cold 
and numbness, slight paresthesia or total anesthesia. Pain, temperature 
and electric sensibility are more affected than other forms of tactile sense. 
Both sides may be involved. A tender spot may be found inside the 
anterior superior spine of the ilium. 

Diagnosis is easy, prognosis doubtful. The general condition should 
be treated, the digestion regulated, various forms of electricity applied, 
and zinc phosphide given a full trial. 

GENERAL CONSIDERATIONS ON TREATMENT 

This chapter will relieve us of the need of dilating on the treatment of 
each malady except as specific remedies may have been developed for it. 

The reader of this section will have noted several peculiarities: The 
maladies described are often rare, many are known by the names of their 
discoverers, their causes are obscure, their diagnosis carefully differ- 
entiated, the prognoses universally bad, the treatment uncertain and 
undeveloped. 



732 TREATMENT OF NEUROSES 

The inference to be drawn is that they became known during a 
period when it was the highest ambition of the investigator to recognize 
a set of associated symptoms to which his own name might be attached, 
and thus be carried to future generations. This required accurate diag- 
nosis, some attempt to elucidate the pathology, but not by any means the 
development of successful treatment. 

It would be well, if this strict limitation of the ambitions of our 
confreres is recognized, to commence attaching the name of the success- 
ful deviser of curative treatment to that of the discoverer of the disease, 
and thus stimulate the search for useful knowledge. But these maladies 
are not entities, and specifics for disease-names are impossible. We 
must therefore fall back for treatment upon the fundamental principles 
of therapeutics and leave to the individual practician the task of fitting 
the particular applications to the particular cases before him. 

The extent to which fecal and other forms of autotoxemia are respon- 
sible for the causation of disease is as yet far from being determined. 
We cannot assign it as a cause of the maladies in question more than as 
a suggestion, for consideration and observation; but we may assuredly 
assume that under no circumstances can the retention and decomposi- 
tion of the bowel contents be regarded as beneficial, or indeed as a 
matter of indifference. Let us commence our treatment, then, by 
thoroughly emptying the alimentary canal, disinfecting it, and keeping 
it clear and clean throughout the course of the attack. 

This may be accomplished by administering calomel gr. J every 
half hour for six doses — if the stools are light colored and offensive — 
followed by enough effervescent saline laxative to produce copious 
watery stools, aided if necessary by colonic flushes. . If the stools are 
dark and offensive, instead of calomel give podophyllotoxin, gr. 1-12 
every half hour. If the stools are not offensive the saline alone may 
suffice, but as a rule the calomel is advisable. Once completely emptied 
the bowels must be kept clear by similar means, a morning dose of the 
saline usually sufficing, aided by an evening grain of calomel occasion- 
ally, perhaps once a week throughout the duration of the malady. 

Disinfection is best attained, after thorough cleaning out, by the 
use of the sulphocarbolates. If the bowels are infected or diarrhea is 
present, give zinc sulphocarbolate one to five grains every one to four 
hours, lessening the doses after the stools become odorless to just enough 
to maintain this effect. If acidity is present, or the stomach is irritable 
to the zinc, substitute the soda salt in similar doses or double those of 
the zinc. But if there is need of tissue reconstruction use the calcium 
sulphocarbolate, also in double the dose of the zinc. In most cases 



TREATMENT OF NEUROSES 733 

the combination of all three, with bismuth salicylate, is preferable, as 
being non-irritating, and the bismuth offers a ready mode of testing 
the antisepsis, as it no longer blackens the stools when sulphides are 
not formed by decomposition of fecal matter. 

The same considerations apply, word for word, to deficiencies 
in the work of the eliminant organs. The retention in the blood of 
substances that should have been excreted by the kidneys, liver, lungs 
and the skin, cannot but exert an injurious influence on tissues already 
weakened by disease, and which require for the restoration of health 
a full supply of the best and purest nourishment instead of being further 
debilitated by saturation with toxins. The estimation of the work done 
and that left undone by each of the great eliminant organs is an imper- 
ative preliminary in the study of all these maladies. 

The way is thus cleared for a study of the patient's nutrition 
and the application to the case not only of the rules of diet but those of 
personal hygiene in general. The success of the physician will largely 
depend on his knowledge of these rules and their practical application 
to each of his cases. We could scarcely forgive the negligence of the 
physician who would leave his patient to poison his blood by inhaling 
the exhalations from decomposing organic matter in his cellar, any more 
than we would if he left him to absorb toxins from his bowels. 

Certain measures will be found to be advocated by all who have 
given special study to this group of diseases. We refer to massage, 
hydrotherapy, graduated exercises, the applications of heat and cold and 
the various forms of electricity. These measures are purely empiric, 
none of them being applied to known pathologic conditions because 
of the known effects these agents have in counteracting those conditions. 
The value of these agents, however, has in a number of instances been 
sufficiently proved, and as methods of exercise and of combating muscular 
degeneration they are too valuable to be neglected. A little of value 
may be found in various special works as to the selection from among 
these means, of special applications to particular instances, but there 
are few exceptions to the general rule that each new case demands 
separate experimentation before the best applications in this particular 
instance can be determined. 

The ignorance of the profession as to the application of drugs in this 
class of diseases is due to the universal neglect of applied therapeutics, 
and the consequent lack of accurate information as to the effects of drugs 
upon the healthy and diseased bodily functions. There is but little there- 
fore that we can suggest today, beyond indicating the lines along which 
clinical experimentation may advantageously be pressed. 



734 TREATMENT OF NEUROSES 

The diet should be arranged with the utmost precision. A due 
supply of each of the essential elements of a perfect diet should be 
secured, proteids, carbohydrates, fats, salts, and water being duly pro- 
vided. Fetor of the stools indicates restriction of the proteids, flatulence 
with other evidences of starch indigestion demands limitation of carbo- 
hydrates; fatty acids in stools or vomit the discontinuance of free 
fats. Gastric indigestion demands hydrochloric acid, intestinal debility 
diastase, and the active principles of bile and of the pancreatic secretion 
are needed far more generally than is comprehended. Either of these 
digestants initiates its digestive process, and as the secretion is auto- 
matic, the secretory glands will complete their task if the food is suit- 
able in nature and form, and not excessive in quantity. In general 
there is innutrition, and the indication is for small quantities 
of easily digested but nutritious food, always warm, to be thoroughly 
masticated and insalivated, and repeated every four hours. All iced 
drinks and foods richly seasoned, condiments, alcohol, and usually 
all caffeine-bearing beverages, are to be interdicted. Milk, eggs, fish, 
oysters, fresh fruit juices and simple carbohydrates like rice and the 
modern partly digested breakfast foods, are usually preferable. Allow 
for due variety. Sometimes the need for thorough mastication is only 
met by the use of hardtack, or oatmeal scones. Milk should be taken 
warm. Clam broth and chowder, and turtle soup, are easily digested 
and nutritious, readily assimilated and well suited for weak digestions 
and low nutrition. Chicken and turkey, sweetbreads, brains, all game 
except water fowl, and even beef, are useful also, but probably more 
cases occur where the system is poisoned with an excess of proteids, 
undigested, than from a deficiency in these articles. A daily supply 
of raw fruit juices containing the still living elements of plant life is 
advisable; and when milk can be had warm from the cow it is prefer- 
able. Individual preferences and appetites are always to be considered. 

The digestive forces may be reinforced somewhat by local feeding. 
The colon may be utilized for the absorption of foods after it has been 
cleansed, throwing about eight ounces of semiliquid food, with artificial 
digestants, into it twice a day. The vagina absorbs foods and med- 
icines better. The skin absorbs fats, and rubbing with hot cod-liver 
oil has afforded valuable assistance in treating many debilitated con- 
ditions. 

Hot brine baths and rubbing with towels dipped in salt water and 
dried are useful measures to attract the blood to the surface where it 
may be oxidized. These may be repeated daily, before the patient lies 
down to sleep. 



TREATMENT OF NEUROSES 735 

Much may be done in the way of preventing paroxysmal attacks 
by attention to the details of personal hygiene — dressing in wool next 
the skin, and hardening by the daily application of cold water to 
the skin, by prescribed exercise, and the avoidance of exciting causes. 
Anstie insisted that a neuralgic required more food than others, and 
that a layer of fat beneath the skin protected the nerves. 

Especially imperative is it to ascertain the quantity of solids excreted 
daily by the kidneys. If this falls constantly far below the normal 
quantity efforts should be made to raise elimination. If the vascular 
tension is not too low the best remedy here is veratrine, gr. 1-134 three 
to seven or more times a day, or three times this dose at bedtime. All 
nitrates and nitrites seem to stimulate the excretion of urinary solids, 
sodium nitrite being especially active, and these may be employed when 
veratrine is irritating to the stomach. Sodium nitrite may be given in 
doses of gr. J every two to four hours. Colchicine, gr. 1-134 increased 
to slight irritation of the stomach and bowels and then given in doses 
just below the irritative point, is useful for the gouty and plethoric. 
The writer has obtained excellent results in this particular from a com- 
bination of phenocoll and piperazin, with abundance of water. 

Even more directly indicated is the use of boldine, by which the pro- 
duction of urea by the liver is stimulated. Of the granules containing 
a milligram each, seven daily form an average adult dose. Since urea 
is the natural diuretic of the body its production seems in the line of 
true "physiologic " therapeutics. 

The special effect of arsenic is probably the production of fatty 
degeneration. During convalescence from acute infectious diseases, 
such as pneumonia or rheumatism, it seems most probable that arsenic 
will favor the process by which the debris of these diseases is melted 
down and carried out of the system, instead of being allowed to remain 
as a clog to the vital functions and a menace to the future health. 
Whenever a similar indication arises in any malady, the use of arsenic 
is justifiable; beyond this it does not seem applicable excepting when 
required to combat certain infections, such as that of malaria, and of 
an as yet undiscovered cause of pernicious anemia. Give small frequent 
doses till the eyelids itch, then keep just below this point for a month. 

The remarkable effects following the use of zinc phosphide as a 
remedy for zoster induced the writer to present the following proposi- 
tion — that wherever a centric nervous degeneration is indicated by local 
cutaneous manifestations zinc phosphide, by improving the nutrition 
of the diseased centers, will act as a prompt and effective remedy for 
the disease. A number of applications of this remedy have confirmed 



736 TREATMENT OF NEUROSES 

the correctness of this proposition. There is room for wide experimen- 
tation, however, before the limits of its applicability will be established; 
and the group of diseases now under consideration offers many oppor- 
tunities for such tests. Recognizing the tremendous metabolic power 
of this drug, and the possibility of harm resulting from its continuous 
administration, it is our custom to advise zinc phosphide to be given 
gr. I four times a day, for one week out of each month, the remainder 
of the month being supplied by the use of neuro-lecithin, another agent 
whose power of improving the nutrition of undeveloped or degenerated 
tissues is attracting attention. Whether the influence of these remedies 
is confined to nervous degenerations or is also applicable to similar 
lesions of muscular fiber, remains to be determined. 

It is now fully established that the administration of nuclein increases 
the number and activity of the phagocytes, but the exact bearing of this 
observation upon clinical practice remains to be ascertained. There 
is a mass of testimony, however, as to the value of this remedy in all 
diseases depending upon invading microorganisms, animal or vegetable, 
verifying the views of Metschnikoff and Vaughan. Nuclein should 
therefore be administered in full doses in every case believed to be due 
to such causes. Of the standard solution a dram each 24 hours is the 
full dose; beyond this the leucocytes quickly diminish in number. 

Another set of observations has shown that in the sulphides we 
possess remedies powerfully destructive to invading microorganisms 
and yet harmless to the human body. The sulphides of calcium and 
of arsenic, if administered until the body is so saturated that the odor 
of these drugs is exhaled with the breath and the perspiration, are 
believed to render the body for the time uninhabitable by any patho- 
genic organism. In a number of infectious diseases this has been well 
proven; in none has it been disproven. The principle is applicable in 
all infections. Give calcium sulphide 5 to 40 grains a day; arsenic 
sulphide gr. 7-67 a day. Saturation is denoted by exhalation of sulphur- 
eted hydrogen by the skin. 

Three remedies are known to exert specific effects upon muscular 
fiber, namely, quinine, caffeine and veratrine. The local effect of 
dilute solutions of either, injected into the substance of diseased muscle, 
seems a legitimate subject for study. Possibly some of the constituents 
of healthy muscular fiber, thus administered, might prove a valuable 
reenforcement to the waning powers of the diseased part. The bene- 
ficial effects obtained by applying nutritives, such as raw blood and 
egg albumen, to the surface of sluggish ulcers, seems to warrant this 
suggestion. 



TREATMENT OF NEUROSES 737 

Excepting to combat anemia there seems to be no good indication 
for the use of iron. That universal stimulant, strychnine, by arousing 
the reserved powers of the system may produce some temporary appar- 
ent improvement. The other so-called tonics are useful if they are 
indicated; but the rash administration of powerful tonic mixtures, with- 
out any special reason for the choice of any one of them, or of the 
whole, excepting that the patient is weak, is a therapeutic method well 
calculated to bring the art into contempt. Too often these remedies 
are employed to increase the appetite, while the bowels are clogged 
and the kidneys failing from over-work. Iron is best given in the 
drinking water, and the addition of nuclein solution enables the body 
to appropriate and retain iron that would otherwise pass through and 
be lost. 

Hemorrhages are best met by the quick application of atropine, 
which dilates the cutaneous capillaries and abstracts the blood from 
the bleeding points. Give a full dose, gr. 1-67, hypodermically, and 
repeat in half an hour if necessary. The vascular tension should be 
restrained by full doses of vera trine, gr. 3-67 at once, hypodermically, 
repeated as needed, and by quickly lessening the bulk of the blood by 
venesection, or depleting enemas of saturated salt solution, cold, thrown 
into the bowel. The bowels should usually be quickly moved by 
elaterin, gr. 1-12 every hour. Fever may be restrained by the defer- 
vescents, veratrine, aconitine and especially gelseminine, either of which 
should be given in small doses rapidly pushed to full effect. Of gelsem- 
inine give gr. 1-250 every ten to thirty minutes till the eyelids droop. 
The simultaneous or subsequent administration of the heart tonics, 
digitalin or cactin, or the vital incitant strychnine, may be indicated. 
Give dose enough — it is not desirable to fetter the practician by too 
close advice as to dosage when cases require such various quantities. 

Many times the influence of absorption stimulants will be required, 
to remove the debris of hemorrhages and inflammations. We have 
long employed the following and come to look upon it as the most 
effective agent of this nature in our experience: Mercury biniodide 
gr. 3-67, arsenic iodide gr. 1-67, iodoform and phytolaccin or stillingin 
gr. J each; all to be given four to seven times a day, stopping and 
reducing the dose whenever the eyelids begin to be irritated, but con- 
tinuing till the need no longer exists. In syphilis nothing so quickly 
puts a stop to the destruction of nerve tissues; in this and other mala- 
dies nothing so powerfully stimulates absorption. The mercury is the 
most powerful of antisyphilitics and absorbents; iodine aids in both and 
renders mercury more prompt, besides carrying it out of the system cer- 



738 TREATMENT OF NEUROSES 

tainly; arsenic iodide is the most active of iodine preparations, 
and by irritating the eyes makes them a safety valve, affording the 
plainest indication of the beginning of toxic action and the necessity 
of diminishing the doses; iodoform aids the iodine effect and subdues 
any gastric irritation caused by the other ingredients. The use of the 
vegetable absorbents is based on theoretic grounds which may or may not 
be true. They are added with the idea that by stimulating the lym- 
phatics they may carry off the debris and leave to the mercury and 
iodine the duty of combating specific infection; besides, experience has 
indicated that they add efficacy to the combination. The whole com- 
bination, in quickness of action and efficacy, far exceeds potassium 
iodide, alone or with corrosive sublimate, 

Counter-irritation is often of value. The most decided benefit is 
obtained from the actual cautery or moxae, but few patients will care to 
bear the pain. The application of lunar caustic to the skin in narrow 
lines is probably the best, as the effects are far more decided and pene- 
trate deeper than those of blisters. The resultant dry eschar does not 
interfere with subsequent applications so much, or constitute a source 
of discomfort or infection. 

Acetanilid is useful to quell painful attacks in robust individuals, 
severe, with or without fever; giving gr. i to 5, guarded with caffeine 
and accompanied with soda, three doses an hour apart. If this does 
not afford relief, other remedies are preferable. 

Antipyrin succeeds best in the lightning pains of ataxia, and is less 
depressing than acetanilid — and less effective. 

Atropine is a powerful remedy for sciatica, lumbar neuralgia, 
uterine pains, spinal irritation, dysmenorrhea, ovarian and intercostal 
pains, and for tic douloureux. It is the great remedy for spasm, and 
more pain is due to spasm than to all other conditions combined. 
When the cutaneous capillaries are spasmodic, the skin shrunken and 
cold, the pulse suppressed and tense, atropine will return the blood to 
the skin and relieve the internal hyperemia. Give to an adult gr. 1-500 
in hot water every fifteen to thirty minutes till the skin reddens slightly 
and the mouth is dry; if relief has not then been secured this is not the 
remedy required — but there are few cases that will resist the king of 
spasmodic pain. A dose of gr. 1-100 injected close to the affected nerve 
will frequently conquer the most stubborn attack. It will not remove 
hyperplastic tissues compressing a nerve trunk. 

Aconitine is indicated by a hard, wiry pulse, throbbing headache, 
evident displacement of blood suspending circulatory equilibrium; 
forms of neuralgia due to catching cold or checking discharges. Of 



TREATMENT OF NEUROSES 739 

amorphous aconitine give gr. 1-134 in hot water every five to twenty 
minutes until there is enough effect on the pulse to show full physiologic 
action; then less frequently. With quinine arsenate aconitine is useful 
in periodic attacks. 

Bebeerine has been recommended as a remedy for periodic cases, 
but this alkaloid having unfortunately acquired repute as a substitute 
for quinine it has never been investigated with a view to establish the 
difference in their powers. Bebeerine however is more astringent to 
relaxed connective tissues than is quinine, standing between the latter 
and berberine. This would indicate its value in relaxed conditions 
and during convalescence. The tonic dose is about a grain before meals. 
Brucine ■ has been advised in hysteric cases, in intercostal neuralgias, 
and for nervous erethism. This alkaloid possesses marked local anes- 
thetic powers and is usefully combined with cocaine when the latter 
does not work well. Otherwise brucine resembles strychnine. The 
dose is about gr. 1-67 every five minutes till evidences of tonic action 
are manifest. Locally a 2 1-2 per cent solution may be employed with 
equal parts of similar cocaine solutions, as an anesthetic. 

Caffeine has also been injected along the course of painful nerves, 
w T ith asserted local anesthetic action, but does not equal brucine. 
Caffeine is useful internally for sciatica and other deep-seated neural- 
gias, and for affections of the brachial and cervical plexuses when 
injected. The dose for hypodermic administration is from one to five 
grains, made soluble by the addition of sodium salicylate. Both must 
be chemically pure — the salicylate if impure or contaminated will make 
the solution pink or even black. The solution may be made by dissol- 
ving 35 grains of sodium salicylate and 40 grains of caffeine in distilled 
water to make two drams. This gives a grain of caffeine to three minims 
or drops. Care must be taken to instantly wash out the needle of the 
syringe after injecting as this solution quickly clogs the small aperture. 
For internal use caffeine valerianate may be given in doses of gr. 1-6 
every few minutes. Other salts do well in hot water; small doses. 

Cannabis is useful for neuralgic headaches and in visceral pains. The 
dose of a good extract is gr. 1-6 every half to one hour till effect, or till 
disturbance of the sense of time or space indicates toxic action. The 
want of a reliable and uniform preparation of this curious drug has hin- 
dered its use. The true remedial principle in it has not been isolated. 

Capsicin is useful in cases developing after the patient has ceased the 
habitual use of ilcohol or morphine; and when the vital depression ex- 
tends to the stomach and absorption is stopped. A small dose — gr. 1-67 
to 1-15 — may be added to other remedies given by the mouth. 



740 TREATMENT OF NEUROSES 

Arsenic is effective as a means of breaking up neuralgic sequences, malarial 
and otherwise; for angina pectoris, and in the neuralgias of frigid, anemic, 
amenorrheic women. Small doses should be given of the preparation select- 
ed, continued for several weeks. In angina pectoris the writer prefers ar- 
senic iodide, gr. 1-67 four times a day, continued for a year if necessary. 

Cocaine gives relief in cases due to overwork, mental strain, anxiety, 
apprehension, grief or other overmastering emotion, and in those stop- 
ping narcotic babits. It is a dangerous remedy, especially to the neurotic, 
and the patient should never be permitted to know that he is taking this 
drug. Disguise it effectually; and in most cases replace it with caffeine 
or brucine. The dose is gr. 1-6 by the stomach, repeated hourly to effect 
for the paroxysms. 

Colchicine has a wider field than is generally believed. It is the reme- 
dy for the plethoric and the uricacidernic, for attacks following indulgence 
at the table(post-Thanksgiving headaches), or from catching cold; and 
whenever there is marked throbbing of the head. The acme of a mi- 
graine usually presents this indication. The dose is gr. 1-134 to 1-30, 
in hot water to hasten its phenomenally slow action, and repeated in two 
hours if necessary. This drug is best given in a single full dose when 
we have learned the patient's reaction toward it. 

The phosphate of copper is said to possess a specific power in reliev- 
ing pains in the fifth nerve. This has also been claimed for aconitine, 
and for gelseminine. The differentiation has not been cleared up, and 
seems doubtful. Luton suggested this salt as a remedy for tuberculosis, 
and it may prove specifically valuable in the neuralgias of these cases. 
The dose is gr. 1-6 every two hours for nine doses a day. 

Croton chloral relieves pain in the scalp ; it has given most satisfaction 
in relieving the tenderness remaining after the subsidence of a neuralgia 
of this region. The dose is a grain every hour till relief. 

Cypripedin and scutellarin are mild but efficient nervous sedatives, or 
rather calmants. They are useful for the depression attending nervous at- 
tacks. An attempt at differentiation has been made by assigning scutellarin 
to cases where the pupils are dilated and cypripedin to those showing con- 
traction. The dose of either is from gr. 1-6 to 1 in hot water every hour. 

There is no place in the treatment of neuralgia, a malady of depres- 
sion, for any of the bromides unless it be camphor monobromide. This 
may be employed in doses of a grain every half-hour during the early 
evening, to secure sleep in prolonged attacks or after their subsidence. 

Delphinine has been advised in obstinate facial and cervical forms. 
It combats vasomotor spasm and any irritation or excitement in the geni- 
tal sphere, and may be employed in such cases. The dose is gr. 1-67 hourly. 



TREATMENT O? NEUROSES 741 

Digitalin has been advised in sciatica and in aural neuroses. Its 
administration should be regulated by the tension of the pulse. 

Emetine may be given to relieve the stomach of a fermenting mass 
and to stimulate the liver — a grain at bedtime. Sometimes the physician 
who has been vainly administering direct analgesics is mortified when 
an emetic reveals and removes the cause of the suffering. 

Ergotin has proved useful in obstinate gastralgia with pulsation of 
the abdominal aorta. It was given hypodermically in doses of gr. iij 
three times a week. The applications of this remedy might be amplified. 
As a vasomotor contracter it has been urged wherever this condition of 
the nerve centers exists. 

Eserine has been applied with good effect for neuralgias of the eye- 
ball; the ordinary solutions of the oculist being used. 

Gelseminine subdues sexual irritability and is applicable to neuroses 
of this tract. It has been advised for dental pains also, with less evidence 
in its favor. Ovarian and testicular pains are quite certainly controlled 
by this agent in moderate doses — gr. 1-250 every half-hour, in hot water 
or hypodermically, until relief follows or the droop of the eyelids signifies 
the limit of its useful administration has been reached. If relief has not 
then been secured the condition-diagnosis has been erroneous, and other 
remedies are indicated. 

Iodine may be employed for a syphilitic taint, or to stimulate the ab- 
sorption of encumbering debris along the course of the affected nerve. 
The latter indication is apt to present itself in any inveterate neuralgia 
whether the painful points of Valleix are demonstrable or not. Massage 
is a useful adjuvant when exudative masses are found along such nerves 
as the sciatic. 

Glonoin is the most active agent we possess to dilate the arteries, and 
acts more quickly when given by the mouth and stomach than it does 
hypodermically. It is indicated when the cutaneous vessels are spastic- 
ally contracted; atropine being added to prolong the effect. Whenever 
any remedy is administered whose action it is desirable to accelerate, 
the addition of glonoin by opening the vessels secures this object. The 
ordinary doses are too large — glonoin gr. 1-250 will sometimes cause 
unpleasant cerebral fullness, and half this dose repeated every five minutes 
is preferable. 

Macrotin is available for ovarian and uterine pains, for spinal irrita- 
tion and possibly for fifth-nerve neuralgias. The dose is from 1-2 to one 
grain, in hot water, every half hour till relief or nausea occurs. 

The injection of solutions of osmic acid along the course of an affected 
nerve has been employed instead of excision — the acid destroying the tis- 



742 TREATMENT OF NEUROSES 

sues. We are not believers in the destruction of diseased tissue, preferring 
to cure it; and when such a measure is unavoidable prefer clean surgery 
to the application of an agency less readily limited to desirable effect. 
The one per cent solution in distilled water is employed, of which a few 
drops may be injected. 

There is an indication for zinc phosphide, in breaking up severe and 
obstinate attacks. If the therapeusis is timid and tentative habituation 
will ensue and relief be imperfect; whereas if the remedies are powerful 
and thrown in vigorously in maximal doses, the effect will be decided. 
Quinine gr. 2, zinc phosphide gr. 1-6, strychnine arsenate gr. 1-30, ext. 
cannabis gr. 1-2, given together and repeated every 4 hours, is a model 
formula for this indication. Zinc phosphide is unsuitable for cases due 
to cold or to inflammation, or for plethoric persons. 

Quinine is employed to forestall attacks of periodic neuraigia, and 
for supraorbitals. A full dose — gr. 15 of the bisulphate — may be 
given six hours before the expected attack; or the arsenate or hydrofer- 
rocyanate in small doses every waking hour. 

No one quite appreciates the value of salicylic acid until he adminis- 
ters it in doses of gr. 1-6 every half hour. The constant instillation of 
this minute dose prevents the growth of microorganisms and ferments 
in the stomach far better than a bulky doses given at long intervals. Cases 
dependent on such fermentation, or on uric acid, rheumatism, etc., and tic 
when attended with acidity, are amenable to this agent. 

Solanine is a drug with a future. It lessens the irritability of the sen- 
sory nerve-ends, gives tone to the capillary walls and relieves hyperemia 
of the nerve centers. In sciatica, gastralgia and other neuralgias it has 
replaced morphine with advantage, proving effective without the dis- 
astrous possibilities following the use of opiates for recurrent pain. The 
dose of solanine is gr. 1-12 for an adult, every hour till irritation of the 
fauces denotes the limit of its therapeutic benefits. 

Strychnine ranks deservedly as the best all-round remedy for neur- 
algia, both for breaking a paroxysm and for the intervals. It is especially 
useful in visceral forms, for those dependent on sexual and other excesses, 
and whenever there is relaxation of tissue or languor of function in evi- 
dence. The various salts are to be applied as indicated; the arsenate 
for most cases, the hypophosphite when developmental nutrition in the 
young is obviously at fault, the nitrate for alcoholics and when the renal 
elimination of solids falls below normal, the valerianate for speedy effect 
and when nervous equilibrium is lost. The doses should be arranged 
with scrupulous care. Many persons can bear no more than gr. 1-67 
every two to four hours; some have taken with advantage a grain within 



TREATMENT OF NEUROSES 743 

24 hours. The dose must be gauged strictly by the effects, the pulse- 
tension being perhaps the readiest indication. Strychnine can be con- 
tinued with advantage for a month; rarely longer. 

When the pulse is hard and wiry, the patient plethoric, the heart hyper- 
trophied, the renal or other elimination markedly defective so that convul- 
sions are possible, the remedy is veratrine. This agent relaxes the vas- 
cular tension with certainty, the effect being prolonged to any desirable 
period by careful dosage to effect. Muscular pain and soreness subside 
under this drug. It acts on all the eliminants, kidneys, skin and liver; 
and as there is a toxemia present in very many cases of neuralgia the in- 
dication for this agent occurs far more frequently than is suspected by 
most physicians. Veratrine should be given to adults in doses of gr. 1-134 
freely diluted, every half hour till nausea or softening of arterial tension 
denotes full useful effect. If acute or subacute gastric catarrh is present, 
or if the patient is very susceptible to the local irritation caused by vera- 
trine, there will be manifested a sense of heat defining the limits of the 
stomach; contraindicating the further use of the remedy by this route. 
The combination of atropine with veratrine has not been tried so far as 
we know, but might prove effective when the cutaneous vasomotor spasm 
is marked and elimination low. 

In the foregoing outline the term "neuralgia" is employed in the widest 
sense — rather etymologically than pathologically — as it appeals to the 
clinician in this way. It is nerve pain he is called to relieve; and the 
institution of effective therapeusis can not be too prompt for the suffer- 
ing patient. The pathologic diagnosis may wait. 

From this long list of remedies the reader may judge of the wealth 
of our resources for the relief of nerve pain. As we use and study these 
uniformly acting agents it is evident that most important discriminations 
as to their applicability in various conditions are to be made. While 
men gave conglomerations of them without much discrimination such 
accurate differentiation was impossible. Nearly every prominent alkaloid 
is a member of a group of closely allied agents, which are at present only 
known to "resemble" it in a general way, but which will undoubtedly 
prove to possess special properties of value when studied. W 7 e know 
for instance that brucine possesses a local anesthetic power not enjoyed 
by strychnine; but what about thebaine, laudanine, calabarine, gelsemine, 
and the rest of the tetanizant group? We know nothing beyond their 
general resemblance to strychnine. The study of such groups, under 
the conditions presenting with modern physiology, may be expected 
when the therapeutic revival we advocate becomes general. 



PART IX 

DISEASES OF THE MUSCLES 



INFECTIOUS MYOSITIS 

A primary acute or subacute inflammation of voluntary muscles 
due to an unknown microbe. It affects all the muscles, the muscular 
fibers and to some extent the connective. Commencing with hyperemia, 
exudation of leucocytes follows, the muscular fibers become hard, fragile 
and fatty. Serous infiltration and connective hyperplasia ensue. The 
disease is most frequent in young men. The causes are unknown. 
(Look for the gonococcus.) 

The malady begins in the extremities and extends to the body. 
The muscles swell, become firm and stiffen. Tenderness may be present, 
with slight edema, extending with the disease; erythema appears, followed 
by pigmentation. Fever and enlargement of the spleen occur early. 
As the muscles of respiration and deglutition are involved, these func- 
tions are seriously hampered. Pulmonary inflammations may compli- 
cate or end the case. 

Trichinosis presents the great diagnostic difficulty and requires 
microscopic examination of the muscular fiber. In multiple neuritis 
there is neither swelling nor edema. 

Acute cases occupy two months, chronic ones two years — more or 
less. Death ends the case, by respiratory implication or complication, 
unless the heart muscle is attacked. There is no known treatment — 
which means that the way is clear for the trial of new methods. If the 
disease is due to a living organism it must be amenable to calcium and 
arsenic sulphides; it cannot but be aggravated by intestinal autotoxemia; 
the x-ray, static electricity, heat or cold must affect the disease in one 
way or the other. The rarity of the malady has prevented extended 
observations. 

PROGRESSIVE SPINAL MUSCULAR ATROPHY 

An atrophic process arises in the anterior cornua of the cord; the 
ganglion cells and the nerve fibers and supplied muscles degenerate. 
Sclerosis may involve the pyramidal columns. In hereditary cases it 



746 PROGRESSIVE NEURAL MUSCULAR ATROPHY. 

develops in childhood. It is most common in men after the 20th year 
and follows over-exercise. 

The thenar and hypothenar eminences become soft and flat, lose 
power, stiffen, coordination is difficult, the thumb lies parallel to the 
fingers, and the degeneration of the interossei shows in grooves between 
the metacarpals. The deltoid is next to be affected, and the other hand 
shows the malady. The quadriceps femoris first shows it in the legs, and 
various groups of muscles are successively attacked, showing fibrillary 
twitching, wasting and the reaction of degeneration. Hypertrophy 
and spastic paralysis rarely occur. Twitching may be developed by 
slight irritation. The diplegic reaction consists in the development of 
contractions in the opposite arm when the anode is placed in the carotid 
fossa and the cathode over the spine. The reflexes lessen with the 
atrophy. Voluntary motion is for a time compensated by calling other 
muscles into use, but gradually fails. Late, the diaphragm is affected, 
and symptoms of bulbar palsy arise. The pupillary reflexes are rarely 
disturbed. Sweating occurs freely. Death comes from inspiration 
pneumonia. 

The order of implication is different in chronic anteropoliomyelitis, 
and paralysis comes earlier. Spasm appears in amyotrophic lateral 
sclerosis. Disturbed sensation, pain and trophic lesions are present in 
syringomyelia and pachymeningitis cervicalis. Local evidences are to be 
found in Pott's disease. In peripheral neuritis the fingers are unequally 
affected and the deltoid is not. Joint symptoms occur in arthritic 
atrophy, and in muscular atrophies due to excessive use improvement 
follows rest and treatment. 

The prognosis is bad, the malady tedious, and patients are apt to die 
of pulmonary intercurrents. 

Treatment is dubious. The usual measures are advised rather 
hopelessly: massage, various forms of electricity and hydrotherapy, and 
dry hot air. Gowers advised hypodermic injections of strychnine nitrate 
in advancing doses. 

PROGRESSIVE NEURAL MUSCULAR ATROPHY 

Nervous followed by muscular degeneration, contractures, sensory 
disturbances and loss of reflexes. Chronic interstitial neuritis arises, 
with connective hyperplasia and atrophy of the nerve elements. The 
degeneration extends to the posterior columns of the cord. The disease 
is probably inflammatory. Many cases are of nervous heredity. Men 
are most frequently affected, beginning between the ages of 10 and 20. 



PSEUDOHYPERTROPHIC MUSCULAR PARALYSIS. 747 

The atrophy begins in the muscles of the toe extensors, peronei, 
small foot muscles, thenar or hypothenar eminences, and interossei. 
The malady is usually symmetric. The feet soon club, the toes claw, 
the foot drags, and in the hands the balls of the thumb and middle finger 
flatten. As the interossei atrophy, grooves appear between the meta- 
carpals and the hand claws. The fibrillary twitchings are severe. 
The calf, forearm, thigh and arm are involved, spastic contractions occur, 
and loss of electric irritability or the reaction of degeneration occurs. 
Even in muscles not yet showing disease the reactions are weak. 
Tendon reflexes soon subside. Sensation may be weakened, tactile, 
pain and temperature; paresthesia occurs, sometimes quite decided pains. 
General health and nutrition are unaffected. 

The sensory disturbances differentiate from spinal atrophy; the 
absence of sphincter disorder from ataxia; the period of appearance 
and progress from infantile palsies. The course' is slow and does not 
threaten life but the chance of cure is small. Treatment? 

Dejerine describes an infantile hypertrophic and progressive inter- 
stitial neuritis, with similar muscular symptoms but also ataxia, lanci- 
nating pains in the limbs, marked sensory disorder. Romberg's sign, 
mvosis, weak pupillary reflex and nystagmus. The nerve trunks are 
enormously hypertrophied. The muscles are degenerated, the nerves 
show connective hyperplasia, the posterior columns also are degenerated. 
The malady appears to be hereditary. Romberg's sign consists in 
swaying of the body when standing with the feet close together and the 
eyes closed. 

PSEUDOHYPERTROPHIC MUSCULAR PARALYSIS 

While the electric reaction of the muscles is unaffected there is a 
loss of motor power, as they increase in size and firmness. The fat in 
the perimysium internum increases; the muscle fiber being normal, 
atrophied or hypertrophied, as well as the connective. The nerve fibers 
are not affected. The disease is passed by females to males. There 
is sometimes a connection with mental disorder, and Gowers traced a 
dependence on consanguineous unions when repeated. The malady 
appears in early life and cases beginning subsequent to puberty occur 
in women. 

The calf muscles enlarge, less often those of other regions, as the 
masseter and infraspinatus, contrasting markedly with unaffected 
muscles. Fibrillary contractions are infrequent. Electric reactions are 
merely weakened. The gait is uncertain and waddling. The patient 



748 PROGRESSIVE MUSCULAR DYSTROPHY. 

has difficulty in rising from lying down, and does so in a characteristic 
manner, getting on hands and knees, then extending the legs, placing 
one hand on a knee and pries himself up. Later the affected muscles 
atrophy, contractures cause clubfoot or spinal curve, power gradually 
fails and the patient dies of progressing debility. The intellect may be 
undeveloped or deranged. Epilepsy is sometimes present. In the 
forme fruste the atrophy sets in rapidly. The diagnosis is easy, prog- 
nosis bad, the only definite suggestion as to treatment the use of massage 
and muscle training, to retard progress. 

PROGRESSIVE MUSCULAR DYSTROPHY 

In Erb's type a primary myopathy begins in the muscles about the 
scapula at the time of puberty. The muscle fibers are irregularly 
atrophied and hypertrophied, striation disturbed, nuclei multiplied, 
connective hypertrophied, the nerves and cord showing no alteration. 
The malady is usually hereditary, sometimes sporadic; appears after 
emotional storms or overexertion; affects the sexes equally, and rarely 
appears after the 20th year. 

The pectorales and latissimus dorsi are first affected, then the serrati, 
spinal muscles, forearm flexors and long extensors, glutei, quadriceps 
femoris; the muscles least likely to be affected being the sternomastoid, 
spinati, deltoid, sartorius and calf group. As the muscles waste, the 
strength, reflexes and electric reactions lessen. The reaction of degen- 
eration is not presented. The atrophy causes the scapulae to project 
like abortive wings; lordosis arises from the loss of support; the per- 
formance on arising is that described in the preceding article; and facial 
involvement may cause difficulty in whistling, speech or closure of the 
eyes. Dyspnea — fatal — may follow involvement of the diaphragm. 
Motion is impaired, the gait is waddling, but sensation is unaffected 
and the sphincters are not involved, nor do bulbar symptoms appear. 

Diagnosis may be difficult if the face is involved. The history and 
age when attacks begin are significant. Prognosis is hopeless. The 
course is slow and progressive, running for many years. Treatment 
remains to be developed. 

In the Dejerine-Landouzy type the muscles of the face, shoulder 
and arm are affected, the fades myopathica appearing. The histologic 
changes are similar to those in Erb 's type. Heredity is manifest. The 
affection begins about the 3d year, in either sex, affecting but one 
sex in a family, and is sometimes preceded by an acute infection or by 
some nutritive disorder. 



ARTHRITIC MUSCULAR ATROPHY. 749 

The muscles of the eyelids and mouth degenerate, the upper lid fails 
to cover the globe, the under droops, the upper lid wastes, wrinkles 
disappear and the face is stupid. Facial movements are lost and the 
eyes become fixed. The shoulders next atrophy: the trapezii, rhom- 
boids and pectorales; then the deltoids, bicipites, tricipites and extensors. 
The muscles of mastication and those of the forearm and hand are least 
likely to be affected. The scapulae project and are abnormally movable. 
Electric reactions diminish as atrophy increases. Tremor is rare. 
Strength lessens as wasting increases. Sensation is unaffected. 

Spinal, neural and congenital forms are to be distinguished by the 
history and the absence of sensory disturbance, tremors, twitching and 
the reaction of degeneration. The course is slowly progressive, prog- 
nosis hopeless, duration very long, treatment still open for discovery. 

Leyden's hereditary muscular paralysis affects children between 
8 and 10 years of age. It is hereditary and affects the muscles as in 
the pseudohypertrophy, but without an increase in size. 

ARTHRITIC MUSCULAR ATROPHY 

When a joint has been temporarily disabled by inflammation the 
muscles commence to atrophy. The muscle fibers shrink, the nuclei 
proliferate, the striation grows indistinct; the nerves remain unaffected. 
If this were due solely to disuse all the muscles would be affected equally, 
but this is not the case, and the atrophy supervenes too quickly sometimes. 
It is attributed to reflex action for want of a better explanation. 

The wasting occurs quite rapidly, the electric reactions weakening, 
the reaction of degeneration being absent, the irritability to stimulus 
and the reflexes greatly increasing. Fibrillary twitching may occur. 

The diagnosis is simple, and usually improvement follows subsidence 
of the arthritis, but atrophy may persist and contracture follow. Treat 
the arthritis, and as soon as it has subsided apply gentle massage and 
faradism to the affected muscles. 

Muscular atrophy also follows other injuries, fractures of bones, and 
prolonged overstrains. Massage, faradism and local feeding by rubbing 
hot oils well into the skin, are useful. 

Muscular hypertrophy occurs idiopathically, the fibers developing, 
with slight evidences of degeneration. The cause is unknown, but 
neurotic ancestry has been established. The muscle enlarges and in- 
creases in strength, but is susceptible to fatigue readily, and sometimes 
the strength is diminished. Diagnosis from pseudohypertrophy may 
be difficult. Prognosis is bad; no known treatment. 



750 MYOTONIA 

MYOTONIA 

Congenital myotonia is a hereditary affection in which muscle 
groups voluntarily contracted remain for a brief period in contraction 
which slowly relaxes. The peripheral nerves are unaffected. The 
muscle fibers are short and thick, the nuclei multiplied, protoplasm 
cloudy, sometimes vacuolated, and the connective normal. Heredity 
is established. Excitants are overexertion, emotion during pregnancy, 
exposure to cold, fright, or other emotional shock. The neurotic con- 
stitution underlies. It develops early, sometimes with mental disease. 

When after rest the patient attempts to put a set of muscles into 
active contraction, the subsequent relaxation is delayed for perhaps 
half a minute. If the same movement is repeated, each time the relax- 
ation recurs quicker until it is normally performed. The entire muscu- 
lar system may be affected but usually the muscles of the face escape, 
except those of mastication. Painful injuries result from the delay of 
successive motions. The arms or the legs may be alone affected. 
Moderate exercise, heat and mental equipoise lessen the difficulty, which 
is increased by excitement, cold or fatigue. The pharynx, sphincters 
and unstriated muscles are never involved. No pain is occasioned 
except slight cramp. Sensation is unaffected. The patient grows irri- 
table, misanthropic or melancholy. The reflexes may be normal, 
increased or lessened. Mechanical irritation of the motor nerves is 
normal or lessened, of the muscles increased and slowed with slower 
relaxation; faradic irritability of nerves normal, of muscles causes long 
contractions; galvanic irritability quantitatively increased, qualita- 
tively altered — ACC equaling KCC — all contractions, slow,, tonic and 
prolonged, and rhythmic contractions passing over the body in waves 
moving at the rate of one to three per second. The muscular develop- 
ment is that of an athelete without the power. 

Diagnosis is obvious. In pseudohypertrophic muscular paralysis 
the muscles are weak and do not give the myotonic reaction. In tetany 
the contractions last longer, the pain is severe, and Trousseau's sign is 
present, muscular spasm on pressure over large detached arteries or 
nerves. In spastic paraplegia and Little's disease the spasm is per- 
manent. In occupation neuroses the spasm appears only on certain 
movements being attempted. Hysteria presents its stigmata; the patient 
carefully avoids disfiguring injury and the electric reactions are 
absent. 

Prognosis is hopeless. A remission may occur, and in one case proved 
permanent, following the lady's marriage. Life is not abbreviated" 



MYASTHENIA GRAVIS 751 

unless through injury received in falls. Treatment is unsatisfactory. 
Patients learn certain means of mitigating their distresses. Exposure 
to cold, and emotional stress, are to he avoided. 

MYASTHENIA GRAVIS 

In asthenic bulbar paralysis the only changes found are in the elec- 
tric reactions of the muscles. There is progressive weakness, with 
increased susceptibility to fatigue, and the myasthenic reaction. The 
cause is unknown. The pathology is undiscovered. It affects particu- 
larly the muscles concerned in mastication, deglutition and speech, and 
the eye group, in varying degrees. The body muscles are weakened. 
Dyspnea may arise, with difficulty on walking. The striking feature 
is the quick development of fatigue on exercise. Hence the eyelids 
droop. The reaction of myasthenia — at each repetition of faradic con- 
tractile force the contraction is less until it ceases to occur. 

The course is variable; remissions occur, the patient dying anally 
of exhaustion or dyspnea. Some choke when trying to swallow. 
Women are worse during menstruation. 

While the malady resembles ordinary bulbar paralysis, there is no 
reaction of degeneration here, no myasthenic reaction there; and the 
unaffected muscles are not specially liable to fatigue. In polyencepha- 
litis we have oculomotor nuclei lesions, a sudden onset, muscular wasting, 
and degeneration reactions. 

There is no known treatment. The stomach tube may be required 
to prevent choking. 



PART X 

INTOXICATIONS, ETC 



ALCOHOLISM 



The immoderate use of alcoholic drinks gives rise to two forms of 
poisoning — the acute and the chronic. The acute form may appear in 
the form of mania-a-potu, or alcoholic delirium. Additional potations 
reduce the victim to alcoholic coma. Delirium tremens is a form of 
alcoholic insanity, while the term dipsomania is applicable to cases 
where periodically an irresistible impulse for alcoholic debauch arises. 

Pdthology: — When death occurs from acute alcoholism the brain 
and kidneys are hyperemic, the mucous membrane of the stomach and 
duodenum likewise congested and covered with mucus. Chronic 
alcoholics show degeneration of the specific tissues of every organ in 
the body, with hyperplasia of the connective envelops, the process begin- 
ning with the stomach and duodenum, and following the alcohol to the 
liver, the nervous and other tissues throughout the body. The degree 
of degeneration depends on the length of time during which the alcohol 
has been habitually taken, the early age at which it was commenced, 
the manner of taking, and the resisting power of the tissues. Fatty 
degeneration is especially prominent in those who drink malt liquors, 
While connective hyperplasia and subsequent cirrhosis characterize 
the spirit drinker. The stomach is always catarrhal; in the drinker 
of beer it is also dilated. Changes in the kidney follow those in the 
liver. Arteriosclerosis is a result of either form of liquor. Sclerosis 
occurs in the brain, with chronic pachymeningitis, serous effusions, 
atrophy and in many cases alcoholic neuritis. 

Etiology: — The craving for alcohol is transmitted. The writer 
knows one family in which every male for nearly two hundred years 
has displayed the craving for alcohol. Children of alcoholic parents 
display an unusual fondness for spices and foods and drinks with sharp 
decided flavor. Alcoholism is one of the interchangeable neuroses, 
and the inebriate's children may display their heredity in insanity, 
idiocy, deaf-mutism, epilepsy, neuralgia, neurasthenia, drug habits or 
diabolic depravity, as well as alcoholism. Conversely, either of these 



754 ALCOHOLISM 

affections may be transmitted to the children in the form of an alcoholic 
tendency. 

Many persons who do not inherit this craving become alcoholic 
through the occasional use of this drug as a remedy for ill-health, as a 
means of temporarily increasing the power for work, for convivial pur- 
poses, or simply as a habit, thoughtlessly and unconsciously formed. 
There seems to be no reason for doubt that many persons form the 
alcoholic habit unconsciously, by taking patent medicines; but the vast 
majority of inebriates is recruited, from the great army of the neurotics. 

Symptoms: — From beginning to end the effect of alcohol is para- 
lyzing. It relaxes the vasomotors, allowing an increased quantity of 
blood to pass out of the arteries, especially to the skin and the brain. 
A sense of warmth and well-being follows. Self-consciousness is first 
affected and the victim forgets himself in his interest in the subject 
matter of conversation; he therefore speaks out with confidence and 
fluency, which gives him and others the impression of a stimulation of 
the mental powers. Repeating the doses of alcohol, the increasing 
paralysis of the nerve centers is shown by muscular incoordination, 
paralysis of judgment and consequent improper, incoherent or delirious 
speech, the loss of self-control, imprudent expressions and quarrelsome 
tendencies, or the delirium of exaltation. Gradually paralysis of mus- 
cular power supervenes; consciousness is more and more overwhelmed 
until the patient sinks into alcoholic sleep, coma or stupor. The res- 
piration is stertorous, face congested, pulse slow and weak but full, the 
skin cool, the breath alcoholic, the urine and feces sometimes incon- 
tinent and the entire muscular system in a state of complete relaxation. 
This lasts a variable time, according to the quantity of alcohol absorbed. 
On awaking the patient is in a state of profound toxemia, with throb- 
bing headache, nausea, anorexia, scanty excretions and general mental 
and physical prostration. Sometimes the direct effects of the alcohol 
induce an acute inflammation of the stomach or of the kidneys. 

Acute alcoholic insanity may follow a single heavy debauch. It 
may be homicidal or suicidal, or take the form of epilepsy. Acute 
melancholy may develop. Delirium tremens occurs in men who have 
drank excessively for a prolonged period, usually taking scarcely any 
food. It may be regarded as a saturation of the system with unelimi- 
nated toxins. 

Acute alcoholic paralysis sometimes occurs from a multiple neuritis, 
which subsides after a few weeks' abstinence. 

Chronic alcoholism is now looked upon as a disease, although there 
is no question as to the powerful influence exerted over it by the awak- 



ALCOHOLISM 755 

ening of religious emotion, which imparts to the patient a sufficient 
stimulus to his weak will and enables him to conquer the diseased 
appetite. There is no safety for any form of chronic drinker, 
whether it be the man w r ho takes a few cocktails daily, wine for even- 
dinner, or beer with every meal. The tendency invariably is to increase 
the quantity taken, as in time the system gets to depend upon it for 
that sense of comfortable well-being which any healthy man may have 
without alcohol, who keeps his bowels regular and his conscience clean. 
The stomach gives out first, gastric catarrh developing, with anorexia, 
bad breath, difficulty of digestion, a coated tongue, nausea before 
breakfast, and constipation. Muscular tremors occur later; the muscu- 
lar powers decline and the gait becomes uncertain, work grows more 
laborious unless constant stimulation is resorted to. The mental powers 
become fixed, their excursions circumscribed, with decay gradually 
supervening. The moral sense is blunted, but this is a late symptom 
and largely due to the increasing selfishness of the patient. 

If the alcohol be taken in the form of beer the stomach distends, 
while heart, liver and kidneys give evidence of fatty degeneration. 
Wines tend rather to the production of gout and gravel; while strong 
liquors induce cirrhosis of the liver with its sequences of chronic intes- 
tinal catarrh, hemorrhoids, enlarged spleen and ascites, as well as 
chronic interstitial nephritis. Drunkenness is not necessary for the 
development of any one of these groups. The writer recalls a fatal 
case of hepatic cirrhosis, in a very distinguished officer, who never was 
intoxicated in his life, but who probably never missed a day for thirty 
years in which he did not take two or three moderate drinks of some 
strong alcoholic liquor. 

Some cases end in dementia, few in permanent insanity. The 
men w T ho finish by never allowing themselves to become perfectly sober, 
present a characteristic appearance; their bodies are heavy, flabby and 
relaxed, weak in muscular power and deficient in tone. The eyes are 
swollen, red and watery, the face puffy or contracted, showing very 
often a peculiar dusky flush, the vessels of the nose and cheeks dilated, 
the mental and physical capacity gradually reduced, the affec- 
tions lost in overwhelming selfishness, the one point of mental activity 
being the craving for liquor. The heart is weak and flabby, with pal- 
pitations, sharp pains, distress and short breath. The degenerations 
of age come on prematurely. 

Delirium tremens occurs after a prolonged debauch. Usually the 
patient has scarcely eaten anything while drinking, and the symptoms 
were for a time attributed to the lack of food, but it is now admitted 



756 ALCOHOLISM 

that this is really a form of acute toxemia from the failure of elimina- 
tion. The patient awakes with tremor, or is unable to sleep, or fears 
to do so on account of terrible dreams. He talks incoherently and 
sees things that do not exist — usually unpleasant things, creeping and 
crawling creatures varying from bedbugs and roaches to calico anacondas 
and Dolly Varden alligators; in fact, a patient once assured the writer 
that he was prepared to give Noah points as to numerous ommissions 
in his menagerie. Sometimes the hallucinations are graver, possibly 
with remorse commingling, and the patient leaps from a window or 
takes other means of suicide to escape from the supposed pursuit of the 
avenger. Muscular tremors increase, the pulse becomes soft, rapid and 
fluttering, the tongue tremulous, dry, brown and fissured. Subsultus 
tendinum, carphologia, coma vigil and low muttering delirium justify 
the appellation given to this condition of the "typhoid state." The urine 
is notably scanty, the bowels constipated, or there is diarrhea of extra- 
ordinary fetor. The breath is overpower ingly bad, and it is with the 
greatest difficulty that the patient can be persuaded to eat. In favor- 
able cases improvement begins after the third day and convalescence 
follows the first sound sleep. In others the exhaustion deepens and 
death occurs from this Cause, from sudden heart-failure, pneumonia 
or apoplexy. 

Diagnosis: — Persons picked up drunk are sometimes supposed to 
be suffering from opiates, epileptic, uremic or other toxic conditions. 
More frequently the error is the other way, and comatose persons are 
thought alcoholic until the post-mortem discloses the mistake. Alco- 
holic coma is rarely so complete but that the patient may be aroused 
by holding ammonia under the nose, or by pressing on some sensi- 
tive spot, such as the "crazy bone" or the supraorbital notch. The 
complete muscular relaxation, the pupils not contracted, and the alco- 
holic breath are the principal indications. 

When the history of chronic alcoholism is wanting, the diagnosis 
may be made by the morning tremor and vomiting, the mental weak- 
ness and restlessness, and a certain easy way the patient has of assent- 
ing to almost any proposition that may be made to him, or rather to 
her, since this especially applies to women. The flushed face may give 
the sign, or the general relaxation throughout the body. However, 
the diagnosis is usually only difficult when the possibility of alcoholic 
indulgence has not occurred to the physician. 

Prognosis: — In the acute forms the prognosis is good, provided the 
physician can control his patient. When alcoholism coincides with pneu- 
monia there is very little hope. The alcohol habit once established leaves 



ALCOHOLISM 757 

indelible traces in the tissues; nevertheless there is hardly any stage at 
which recovery is impossible. Even though relapses are frequent the 
patient is the better for making the effort to free himself. The immediate 
effects of alcohol subside when it is discontinued, and although the cir- 
rhotic process may not abate, patients who have long been inebriate and 
show well-marked evidences of the disease may live many years in very 
fair health and comfort, with judicious treatment if the alcohol is stopped. 

Treatment: — Generally a drunken man comes out of his coma in due 
time if let alone; but if the evidences of depression are so serious that 
life is in peril the vital forces should be sustained by full doses of strych- 
nine hypodermically, while the remaining alcohol is washed from the 
stomach and its further absorption stopped. It is sometimes imperative 
to sober such a man as quickly as possible. Not infrequently the pre- 
monitory trepidation with which the average man views his approaching 
wedding leads him to indulge in bibulous props until he is reduced to 
coma, with the w r edding only a few hours off. In such cases the stomach 
should be emptied, when a Turkish bath will usually restore the man to 
presentable condition. This is safer and better than a pilocarpine hy- 
podermic, which has been used with success; but as this occasionally 
induces pulmonary edema, the combination might be fatal. 

In all acute forms, including delirium tremens especially, the alcohol 
should be stopped immediately and absolutely. Abundant hospital ex- 
perience has proved the enormous superiority as to results of treatment 
when this is done. This is now so well understood that the solicitations 
of the patient to be permitted to taper off, are no longer backed as formerly 
by the conviction of his friends of the absolute necessity for this procedure. 
At one time it was thought that the leading imperative indication was 
to secure sleep, and many deaths resulted, not only from the opium but 
from the chloral and bromide substituted later. Then came the era of 
heart tonics, and tincture of digitalis was given in enormous doses, with 
better effects. When delirium tremens came to be considered a symptom 
of denutrition, attention was deflected to the stomach, and the patient 
was gorged with food, to his great detriment; but out of this grew the 
most useful expedient yet devised, which was the administration of cap- 
sicum in doses of a scruple and upwards. This proved decidedly bene- 
ficial in two ways — its administration put an instant stop to the patient's 
craving for liquor, and the powerful stimulation of the vital functions 
aroused all the lagging powers and powerfully aided the patient in throw- 
ing off the effects of the poison. 

Finally we have arrived at the true state of affairs. Delirium tremens 
is an acute toxemia, due to the check of elimination. The most effective 



758 ALCOHOLISM 

remedy that has yet been suggested is pure emetine, entirely deprived 
of cephaeline. This is to be given with every precaution to avoid its 
being vomited. The patient is put to bed and given one grain of emetine, 
in tablets, which are to be swallowed whole, if possible, without any liquid; 
the patient is then enjoined to lie perfectly still for fifteen minutes, in 
which time he will almost certainly fall asleep. In eight hours he will 
awake, sane and quiet, will have one or two spinach-colored stools and 
be ready to relish his breakfast. If the emetine is vomited, a similar 
dose should be given immediately.' Obstinate vomiting may require a 
preliminary dose of cocaine or a hypodermic of morphine over the stomach. 

The writer has employed all the methods of treatment above described, 
and others, falling into every error he has charged upon the profession, 
and from his experience looks upon the emetine treatment as leaving 
nothing further to be desired. 

The food for these patients should consist of the most easily digested 
articles procurable, especially the acid meats, like soused pigs-feet, raw 
oysters and beef with lemon juice or vinegar. Following these the 
juice of grapefruits or oranges should be given with lavish hand, with 
raw oysters and eggs, warm milk and coffee. 

The work of elimination should be continued by the use of warm 
baths, massage, and if necessary, flushing the kidneys by saline solution 
introduced into the colon. , Nightly doses of emetine should be given 
to insure sleep and restore hepatic function. 

The treatment of the alcohol habit requires residence in an institution 
for that purpose, for a period of not less than six weeks. The tremendous 
power of suggestion is to be employed whenever there is an opportunity 
The marvels actually obtained by the various secret methods are exclusive- 
ly attributable to suggestion. As a part of this method means are taken 
to render the use of alcohol disagreeable to the patient. For this purpose 
an unpleasant fullness of the head is caused by the use of glonoin and 
atropine, and this is sustained until the dangerous period has passed. 

Persons who persist in the craving for alcohol despite the above reme- 
dies, are given a hypodermic injection of apomorphine simultaneously 
with a big drink of liquor. The resulting effects of the apomorphine are 
attributed by the patient to the liquor, and a feeling of disgust towards 
the latter is induced. In the meantime the patient's condition should 
be carefully studied, and whatever treatment is indicated should be ap- 
plied. The custom of subjecting all these cases to a single routine is 
most reprehensible. 

All patients probably need to have the bowels cleared out by cholagogs 
and salines, the liver unloaded and the nerves quieted with emetine, renal 



ALCOHOLISM 759 

elimination secured, and the diet arranged so as so give a full and ab- 
undant supply of nourishment to replace the false stimulus of the alcohol. 
The food should therefore be highly nutritous, easily digestible, should 
embrace all the groups that form a perfect diet, and shoulcf be given in 
reasonable quantities every four hours. It is impossible to give too much 
fruit juice. Warm baths and massage are of inestimable service in aid- 
ing elimination, and when the patient's strength will permit, the cold 
plunge, followed by a brisk rubbing and comfortable wrapping up in bed, 
causes a sense of comfortable well-being superior to that afforded by alcohol. 

With all this, however, the patient who has long been accustomed to 
alcohol will have a sense of helplessness and relaxation that constitutes 
a strong incentive to a resort to alcohol. This condition, however, is 
forestalled by commencing, as elimination is reestablished, the adminis- 
tration of strychnine. This is to be given in carefully adjusted doses, 
so as to restore and maintain normal tonicity as indicated by the pulse; 
in fact, the patient leaves the institution with the strychnine habit. Under 
judicious management, however, his returning vigor permits a gradual 
diminution of the doses until they may be safely discontinued. Attention 
to elimination and digestion can never be discontinued without the peril 
of a relapse. Patients upward of fifty, who have been twenty years or 
more saturating their nerves with alcohol, will generally take the strych- 
nine the remainder of their lives. To this there is no special objection. 

He who limits his treatment of the alcohol habit to the above con- 
sideration has but a narrow sense of his functions as a physician. A 
close study of these cases will generally disclose causes for the habit in 
the moral sphere, and sometimes these can be remedied. The writer 
has known a confirmed inebriate of many years ' standing to be completely 
cured by separation from an uncongenial wife and marriage to a mate 
who knowingly assumed the responsibility and successfully met it. In one 
case the patient's family noticed that for several days before a debauch 
his stools became fetid and devoid of bile. They were instructed to watch 
for this sign, and whenever it occured he was given a grain of emetine, 
with the result that the sprees were completely prevented. In another 
case the writer accidentally discovered that the man was a lover of flowers, 
and changing his residence from the city in which he languished to a farm, 
resulted in a complete and permanent cure. In still another case the 
craving for alcohol was found to be seated no deeper than a catarrhal 
pharynx, and as this was cured the craving for alcohol disappeared. One 
more instance: A young physician of much more than ordinary promise 
consulted the writer about a growing addiction to alcohol. The fullest 
instructions were given to his wife as to his care at home, he being un- 



760 ALCOHOLISM 

willing to leave his practice and promising the fullest compliance with 
my instructions. A few days after, the writer called at his house about 
ten a. m., and found that the physician had just returned after having 
been out a large part of the night with an exhausting case of obstetrics. 
He sent out for his breakfast, which when brought in to him consisted 
of meat and vegetables which had been placed in the oven when the family 
breakfasted, and when brought to him were so thoroughly dried out as to 
be simply uneatable. The wife was off on a shopping trip. This is a 
fair sample of the attention given' at the patient's home to the physician's 
instructions. The unfortunate man died shortly after of alcoholic pneu- 
monia. 

Sometimes alcohol in the ordinary forms is either inaccessible or the 
patient acquires a craving for something further. In France this is met 
by absinthe; in some countries ether is used as an intoxicant; in others 
essences of lemon, ginger or other volatile oils, or cologne water, are in- 
dulged in. When beverages containing volatile oils are employed, the 
destructive effect of alcohol upon the kidneys is enormously increased. 
Absinthe and probably ginger also impair the structure of the brain, so 
that a distant set of symptoms results therefrom. The effects of ether 
are probably similar to those of alcohol but more quickly induced. 

The utmost care must be had in dealing with women addicted to the 
use of stimulants. The problem is much more difficult than with men, 
for many reasons. Whenever a woman shows the slightest inclination 
to a liking for alcoholic medicines or beverages, the physician should avoid 
their use. Many a woman has commenced the course that leads to in- 
ebriety by the use of coca and other medicinal wines, elixirs or liquors. 
One to whom tincture of capsicum or myrrh was prescribed in ten-drop 
doses increased this until she took a pint of the mixture in 24 hours. Free- 
dom from danger is by no means the least of the advantages accruing 
from the use of the active principles in granules. The diagnosis of al- 
coholism in women is difficult, even to the experienced. An incautious 
movement may lose control of the case, as occurred in the following: A 
physician was called upon for a lady who showed signs of approaching 
delirium tremens. The family could not understand where she got her 
liquor, as they thought they had guarded against every possible source 
of supply. The physician had recently heard of cologne drinking, and 
mentioned it as an example, without a thought that it applied to the pres- 
ent case. But the family, who had never heard of such a thing before, 
at once exclaimed that the mystery was solved, since she bought cologne 
by the gallon. The physician at once realized his mistake. During 
the day he was dismissed from the case, and shortly afterward received 



THE COCAINE HABIT 761 

from private sources an intimation from the lady of her undying resent- 
ment. Had he kept this knowledge to himself, he could by holding it 
over the patient's head have kept her under such control as would have 
permitted a cure. 

CHLOROFORM HABIT 

Of all the drug habits known that of chloroform-taking is the-most 
absolutely incurable when once fully established. Usually the patient 
simply goes to bed with a bottle of chloroform, and keeps up the stupe- 
faction from it as long as the supply lasts. It is said that women once 
addicted to this habit are never cured, the only ends being death and 
the insane asylum. Observations are wanting as to the effects of this 
on the human constitution. The causes are those of drug habits in gen- 
eral — the desire for tempory oblivion. It would seem as if the chloro- 
form habit should be especially prevalent among those who suffer from 
cancer, inveterate neuralgia and other painful disease; but it seems that 
such patients resort rather to morphine. 

If the patient is a woman, a cure can only be wrought through her 
affections. The drug must be at once absolutely and certainly withdrawn, 
and she must not be allowed access to any other narcotic drug, not so 
much as a bottle of essence of peppermint, or a nutmeg, or a piece of 
camphor. This restriction must continue long enough to allow of her 
thoughts and emotions being concentrated upon some object w r ith sufficient 
intensity to replace the picture of the drug. There is no medical or hy- 
gienical treatment for the chloroform habit per se, beyond what may be 
indicated by the condition of the patient outside of the habit. She may 
need tonics, she generally needs cathartics and eliminants, and she surely 
needs an interest in her life superior to that of drug-drunkenness. The 
conditions necessary for a cure are obviously impossible without pro- 
longed residence in a properly equipped institution. 

THE COCAINE HABIT 

The causes of the habitual use of cocaine are similar to those of mor- 
phine, in fact, the majority of cocaine habitues have simply added this 
accomplishment to the use of morphine. We have never been able to 
extract from a cocaine habitue a definite reason for his indulgence in the 
drug. Ask him what pleasure he derives from it, and he cannot tell'you; 
ask him why he takes it, and he has no reply. 

There is nothing to be said as to the effects of cocaine upon the body. 
Its effects as shown in the psychic realm are, however, striking and unique. 



762 THE COCAINE HABIT 

The cocaine habitue may take his drug by hypodermic injections or by 
snuffing it up the nostrils, not very often in any other manner. He never 
takes much, but uses small doses incessantly; he cannot keep still, but 
restlessly wanders up and down, in and out, reminding one of a caged 
leopard. 

One of these patients under the writer's care would get up, take a 
little whisky, then smoke a cigarette, then take a hypodermic of morphine, 
then snuff a little cocaine solution, then take a few drops of peppermint, 
then another cigarette, and so he would go on the livelong day and half 
the night, scarcely permitting five minutes to elapse without taking some- 
thing, until well along into the latter part of the night a huge opiate or a 
dose of hyoscine would put him to sleep for a prolonged period. The 
cocaine user is companionable, quite chatty, tells a good story and appreciates 
one. He sleeps little at night but puts in the time writing interminably. 
In the morning the results of his writing are found scattered over the floor 
or in the waste-paper basket. Gather up the scattered sheets and ar- 
range them, and you will find his productions seem to be quite readable; 
but as you go along you begin to wonder what he is really talking about, 
as there seems to be neither beginning nor end, nor any connected sense, 
nothing but fine sounding phrases without thought back of them. 

The most remarkable effect of this drug is the extinction of the moral 
sense. The opium habitue will commit any crime to obtain his drug 
when the pangs of abstinence are upon him; but the bitterest remorse 
will follow, and in his normal condition of drug-equilibrium his con- 
science is of the tenderest and he would not knowingly wrong any living 
being. The moral sense of the alcohol inebriate becomes blunted as do 
his other perceptions, but it is never lost until his mentality sinks with 
cerebral degeneration. The cocainist is a soulless man; he is capable 
of any crime, and after it will sleep like an innocent child, and crack 
jokes next morning as he thoroughly enjoys his breakfast. As the habit 
progresses, he begins to "see things"; he will come home and coolly and 
unconcernedly inform his family that he has just murdered some one 
under conditions of the utmost atrocity, and that a mob is coming to 
lynch him, which may or may not be true. He is perfectly capable of 
doing this, and sometimes he does it; but he is such an unconscionable 
liar that it may be prevarication, or again an insane delusion. Some 
years ago the writer advanced the opinion, based upon a study of cocaine 
habitues, that the crimes for which negroes are lynched are possibly 
dependent upon their use of cocaine, since this drug has of late years 
come to be habitually used by many of the lower orders of this race. 
This observation is evidently not without foundation, and a number of 



THE .MORPHINE HABIT 763 

the southern states have passed laws forbidding under penalty the sale 
of cocaine excepting on prescription. 

It is this destruction of the moral sense which renders it so difficult 
to cure a cocaine habitue; in fact, the writer believes that a cure is 
impossible unless the patient can be restrained from all access to cocaine 
for the full period of one year. There is no treatment required, no pre- 
caution to be observed; the drug is simply to be stopped, and that is all. 
No symptoms result from the stopping. 

THE MORPHINE HABIT 

Can the morphine habit be cured at the patient's house? Yes, 
provided the doctor has the three prime requisites at his command: 
(1) Complete control of the patient's supply of morphine; (2) the 
patient gives up all work and devotes himself exclusively to the business 
of throwing off the habit; (3) the physician has the necessary means 
and appliances to relieve suffering and the skill to use them properly. 

Without these the most skilful specialist will fail in any but the 
easiest cases. And let us say that the asserted painless cures one reads 
about in the advertising circular are either lies, pure and simple, or they 
are cures of the easy cases, hardly deserving of the name of "habit". 
Nevertheless we must not expect the patient to admit that his was an 
easy case. Nothing affronts a man more deeply than to intimate that 
his own case has not been peculiarly difficult or his suffering phenom- 
enally excruciating. But when one has conducted hundreds of men 
and women through the ordeal of breaking off drug-habits, he learns to 
estimate pretty accurately the relative amount of suffering of each, the 
silent endurance of one of nature's noblemen, and the eloquent exagger- 
ation of the most trifling discomfort on the part of the morphine- 
hungry party, who thinks she will get her drug if she only makes fuss 
enough. 

The specialists who have devoted their lives to the treatment of this 
disease, narcomania, agree in affirming that no confirmed habitue can 
free himself without a struggle, and devote their energies to reducing 
the unavoidable suffering to a minimum, making the ordeal as short 
and as easy as possible. Regnier, Erlenmeyer and Crothers, men whose 
names are known all over the world for their scientific work in this de- 
department, all recognize the truth so well expressed by Hare, that "when 
a patient goes through the withdrawal without suffering, you need not 
flatter yourself that it is on account of your treatment; it is because he has 
a secret supply of his drug." 



764 THE MORPHINE HABIT 

Compare these statements with those of the advertising fraternity 
and it will be seen how far these unknown, often illiterate, individuals 
are ahead of the scientific specialists. The advertisers "cure their 
patients at the latter 's homes, without detention from business; the 
cure is easy and painless; the patient never knows when the morphine 
is withdrawn, so imperceptibly is it accomplished. Any case can be 
cured in periods varying from three weeks down to fifteen minutes." 

That these miraculous powers should be denied to the educated man 
of science and lodged in the hands of these persons would seem remark- 
able, were it not that we know that these gentlemen are not in business 
for their health, and that, viewing the matter from a strictly commer- 
cial standpoint, it has a different aspect than when looked upon from 
the purely scientific point of view. 

Do not imagine that we believe no good can come out of such 
sources. There is some chance of a quack discovering a good thing, 
as well as any one else. The only question is as to whether he really 
has done so or merely claims this credit, which is a very different 
thing. We have taken pains to investigate all these claims which came 
within our cognizance, and these are some of the results of our investi- 
gations: 

A doctor wrote us of a popular "home treatment," saying he had 
known of its success, and had analyzed samples sent at his request, 
and found no morphine in them. By our advice he obtained a sample 
from a patient who was under treatment by it, and in this we found 
abundance of morphine. The remedy for the morphine habit was 
morphine, and the method contemplated a gradual reduction of the 
dose until it was entirely withdrawn. We have met a number of persons 
who had tried this method, and their testimony has invariably been that 
they could reduce the dose to a certain point, when the symptoms of 
withdrawal began, and then they had to increase the dose or add an 
opiate. The withdrawal symptoms will show up whenever the cells 
have been drained of morphine, no matter how slowly it is done. 

Another party stupefies his patient with chloral, keeps him thus for 
some weeks and then sends him home with the assurance that he is cured. 
When the chloral has been eliminated, the withdrawal symptoms appear 
in full force, and the victim has the whole struggle before him, just as 
if he had simply stopped short, only that he is poorer by the sums paid 
for his "cure." 

A third variation of the miracle-cure is to get the patient off the 
morphine and upon alcohol, cocaine, cannabis or codeine. Of these 
drugs alcohol is known to every one, and whether it or morphine is the 



THE MORPHINE HABIT 765 

worse as a habit-drug our readers are as able as we to judge. Cocaine 
is the most disastrous in its effects on the human brain of any habit- 
drug we have ever heard of. Between it and morphine there is no ques- 
tion as to the choice. Cannabis is possibly less injurious than the 
opiates. But as yet no observations upon its effects, immediate and 
remote, upon numerous individuals, have been made public. My own 
experience has been that every case, after using the cannabis for a time, 
went back to the morphine. The same thing is true of codeine. The 
use of these two drugs keeps up the appetite for, and habit of reliance 
upon, a narcotic drug, and keeps the door open for the return of the 
archfiend morphine. 

There is one method of the advertisers that has real value — the elim- 
ination system. By this they guarantee to cure any case of opiate 
addiction in forty-eight hours. The patient is given emetics and 
cathartics until the bowel is completely emptied, the "residual bile" 
and the morphine stored up in the tissues are discharged. If thoroughly 
done, the urine will not respond to the test for morphine. The with- 
drawal symptoms come on at once, and if the patient has the nerve to 
bear them for a limited time, crisis occurs and he is free. 

This method, then, is Lewinstein's abrupt withdrawal, with the 
great improvement of the thorough evacuation and rapid elimination. 
It is suitable for young and strong patients, with sound heart and good 
will-power who have not taken the drug very long or in large doses. 
With the ordinary habitue there are the grave dangers of collapse, 
inflammation of the bowels and a sudden stoppage of the activity of one 
or other of the vital organs, long accustomed to perform its functions 
only under the influence of the drug. These dangers are reduced 
greatly if the patient is under the constant surveillance of his physician 
and the latter has the requisite skill and experience in the treatment of 
drug-cases; but, still, it is a method suitable only for selected cases, and 
not by any means generally applicable. 

Having thus cleared the ground, we are prepared to consider (1) 
what is the pathological condition present; (2) what is the best mode 
of treatment; (3) what results are to be expected from treatment ? 

Effects: — Bacon suggested that a daily dose of opium would prolong 
life; his thought being that by the use of this drug the bodily functions 
would be carried on more slowly and the consumption of vitality would 
thus be lessened. That the-drug has the property of delaying the vital 
functions is true enough; but, unfortunately, it is upon the all-important 
processes of digestion and elimination that it lays its paralyzing 
grasp. 



766 THE MORPHINE HABIT 

The secretion of the gastric juice, of the bile and, in fact, of all the 
digestive principles, is checked; the movements of the intestinal muscu- 
lature and the sensibility of the mucous surfaces are decreased; so that 
the retention of fecal masses is an invariable condition in opium habitues. 
The sense of hunger is removed also, so that the patient really decreases 
his consumption of food to a minimum, but he lives on his own tissues 
instead. The loss of weight is gradual, not apparent for years, perhaps, 
but in the latter days it becomes extreme, the skin hanging loosely upon 
the bones, the thin, poor limbs, the sunken cheeks and lack-luster eyes 
being a pitiful sight. 

In some instances the use of opium restores the appetite and even 
enables the patient to put on flesh; but in every instance of this sort which 
has come under my observation it has turned out that the drug masked 
or held in check some grave structural disease, most frequently an 
affection of some part of the digestive system. 

On the mental functions the use of opium exercises an influence 
closely resembling that of alcohol. The first effect is stimulating; the 
intellect appears to become stronger and clearer for the time; but with 
each fresh stimulation the brain becomes less able to functionate with- 
out the drug. And slowly but surely the mental horizon contracts, the 
range of the mind 's possibilities narrows and its work is more closely 
restricted, until outside of the routine work to which he has been accus- 
tomed, the habitue is incompetent to perform any but the simplest 
exercise of his reason. The story of the latter days of the drug-victim, 
his awful anguish, his unspeakable sufferings and the tortures of his 
remorse, has been told often enough, and we will not repeat the details, 
of which the recollection is sickening even to one who has witnessed 
them many times. 

The decline of physical strength may be long delayed if the daily 
dose of opium is kept down to a minimum, but the downward progress 
is certain, and the patient gradually drops out of the activities of life 
and sinks into chronic invalidism. 

But the most remarkable effects of opium are those it exerts upon 
the tissue metabolism. At first there is a decrease in the excretion of 
toxins, which appear to be retained in the cells. This retention, 
however, soon reaches the saturation point, when the cells can retain 
no more. The decrease in the patient's physical activity and in his 
use of food appears to be in one sense conservative, as the destruction 
of nutritive material and the formation of toxins • is thereby reduced 
to that minimum which the organs are still capable of performing 
and the cells gradually become accustomed to carrying on their work 



THE MORPHINE HABIT 767 

in this manner. They get in the way of doing but little work and of 
throwing off simply the extra portion of the toxines formed, as an over- 
fed babe ejects the milk from its esophagus, leaving the stomach full. 
Moreover, for even this minimum of work they are dependent upon the 
stimulus to the nerves afforded by the opium. The bodily functions 
become so attuned to the morphine key that they can make nothing but 
discords in any other. The significance of this becomes manifest when 
the drug has been discontinued, after the withdrawal period has 
passed and the patient has for some time been trying to live without 
his drug. 

One result of this locking up of excretory matter in the body is an 
increased liability to disease and to grave consequences following injury. 
Abscesses form readily and are slow to heal. Influenza, pneumonia 
and intestinal affections carry off these unfortunates, when healthier 
subjects would recover. 

Finally, opium has a singular effect upon the course of diseases exist- 
ing at the time the habit began. Frequently the drug has been first 
employed to relieve the pangs of neuralgia, of dysmenorrhea, or of one 
of the numerous forms of myalgia. The pain is relieved at the first, 
but it returns with certainty at the usual time, or when the effect of the 
opiate has worn off. Thus it appears that opium checks the natural 
evolution of the disease by which it would otherwise work its own cure. 
The malady is crystallized, as it were, and prevented from either running 
its course or getting well. 

A lady had had repeated attacks of dysentery, for which she took 
laudanum. This kept the bowel affection in check, but it reappeared 
whenever the effect of the laudanum wore off. We found that her 
bowels were loaded to an almost incredible degree with feces, and it 
required the utmost care to dislodge the deposits without setting up an 
inflammation of the bowel. The dysentery was simply an effort of 
nature to get rid of the real difficulty, and this salutary effect had been 
prevented by the use of laudanum, which always relieved the pain and 
soothed the irritated bowel into quietude. 

We are now prepared to consider the question: "What is to be 
accomplished by treatment?" The objects of judicious medication are 

(1) to enable the patient to discontinue the use of morphine safely; 

(2) to diminish the suffering incident to withdrawal; (3) to treat any 
coexisting or underlying disease; (4) to enable the patient to live without 
morphine subsequently and prevent a relapse into the habit. 

We have already mentioned the fallacy of the advertisers who "cure" 
morphinism by eliminating the drug from the system. - Another equally 



768 THE MORPHINE HABIT 

erroneous idea prevails that a cure means to take away the craving for 
the drug. Some persons who have observed cases of alcoholism, in 
which the patient has an unquenchable thirst for alcoholic pharyngeal 
irrigation, proclaim their ability to cure morphinism by removing the 
craving for the drug. In fact, no such craving exists. The drug is 
stopped and eliminated, and nothing but loathing is felt for it, but the 
overwhelming need comes on to force the patient into using it. This, 
however, the advertiser has not promised to remove. 

For the first indication, that of enabling the patient to discontinue 
the drug without danger to life, it is necessary first to study the case. 
The patient should be stripped and examined thoroughly from head to 
foot. His general physique, marks of previous disease or of morbid 
tendencies should be noted. The functions of the brain, lungs, heart, 
digestive and eliminative systems should be carefully scrutinized, the 
abdomen palpated for impactions and the urine tested for albumen, 
sugar, total solids and eliminative capacity. During the withdrawal 
the heart is apt to fail if not properly strengthened beforehand and 
watched closely. Severe diarrhea or dysentery will certainly occur if 
not prevented by suitable treatment. The kidneys may refuse to 
eliminate without the controlling influence of morphine, and uremia 
may occur. Autotoxemia is a certainty and must be reduced to the 
lowest possible point. And when it has been allowed to occur, it brings 
with it melancholy, in the form of a settled conviction that the whole 
thing is useless, that life is not worth living at the best and death a 
certainty in the near future, and it is best to take enough morphine to 
enable one to settle up necessary business matters and then quit. But 
when the body is again saturated with the drug the morale is restored, 
and the patient then desires as ardently as ever to break his chains. 

The relief of the suffering occasioned by depriving the patient of his 
accustomed drug is the second object of treatment. Much may be done 
in this way; so much that it is often a question if we are not doing too 
much, as the patient may be encouraged to return to his habit in the 
confidence that he can be so easily cured. 

This parallels the drunkard who is so easily delivered from the 
horrors of delirium tremens that he goes gayly back to his potations in 
full confidence that "Doc will pull me through." (Our apologies to 
those who object to the familiar abbreviation, but it is the way he says 
it; for the inebriate has no respect for aught on this mundane sphere, 
and would address the President as "Old Hoss.") But cases differ. 
There are young and healthy men who have so little excuse for their 
drugtaking that one feels that they ought to suffer the full measure of 



THE MORPHINE HAB1 T 769 

the withdrawal pangs. We have profound sympathy with misfortune, 
but none for "pure cussedness. " But when we deal with an old and 
broken man, when we seek to remove the prop on which he has learned 
to sustain himself, we must go easy; we must be most merciful, and only 
slip away the crumbling staff as we transfer his grip to a stronger, more 
enduring support. Nothing is more touching than the confidence with 
which one of these noble martyrs says: " Doctor, I will bear all my suffer- 
ing with fortitude, for I know you won't let me suffer more than is abso- 
lutely necessary." One feels like bringing every aid that experience 
can supply to save such men every pang; and it is one of the pleasures 
jf life to have one of them realize with surprise that the dreaded ordeal 
has slipped by while he has been still looking forward with anxiety. 

Many morphinists have underlying disease, perhaps unsuspected 
masked by the drug. It may be neuralgia, dysmenorrhea, diabetes, 
dyspepsia, or other disease that may fairly come within the reach of 
curative treatment. But suppose it is cancer, tuberculosis or mucous 
colitis? What becomes of the "sure cure" guaranteed? The quack 
does not guarantee to cure these diseases, he only cures morphinism. 
But the only thing left for such unfortunates is to go back to the drug 
as quickly as possible, for in these affections morphine alone makes life 
bearable. And it really seems to hold the disease in check, for it will 
progress rapidly when the drug has been withdrawn. The only effect 
of treatment in such instances is to transfer the patient's money to the 
quack and subject the victim to the misery of a useless and exhausting 
ordeal which he never should have been permitted to undergo. 

And when all these things have been done and the patient has been 
relieved of the drug, has regained his normal health and is well, fat and 
happy, eating voraciously, plunging into his tub of cold water with a 
delight he would not have believed possible, and enjoying the exquisite 
sense of rejuvenation that follows the reaction, the hardest task of all 
yet remains: that of enabling the patient to live without his drug. The 
chains of habit are strong. When for years one has accustomed himself 
to innervation for a bad surgical operation his hands will travel uncon- 
sciously towards the hypodermic syringe, and he will have the "shot" 
prepared before he realizes what he is doing. 

And metabolism lags. The functions are performed languidly, and 
toxins are imperfectly eliminated. The body-organ has been attuned 
to the morphine key and makes nothing but discords without the 
master's touch. Toxins accumulate, and digestion, assimilation and 
nutrition are sluggishly accomplished. Ashes form over the glowing 
embers. Oxygenation is imperfect and the temperature falls below 



77o THE MORPHINE HABIT 

normal. Spasms of some portion of the respiratory apparatus occur; 
hiccough, tonic spasm of the diaphragm or of the glottis; palpitations 
and spasmodic pains around the heart frighten the patient with the idea 
of angina pectoris; and a person is only too apt to seek relief where he 
knows it can be found. The habit of " bracing" before undertaking 
any task becomes a second nature, and it is sometimes a difficult task 
to teach a patient that he must rely on his own unaided powers in all 
the emergencies and viscissitudes of life. 

Treatment: — We approach this part of our subject with reluctance; as 
it is difficult to give anything like a really clear idea of a treatment 
that will be applicable to the generality of cases. We have several 
times believed that our treatment was systematized, but it has proved 
that this was an error; the cases we had treated were exceptional, and 
the treatment that had succeeded with them proved useless in the sub- 
sequent trials made with it. 

The first essential is getting control of your patient. This must be 
absolute. Unless he will surrender to you the control of his morphine 
supply, you may as well stop right there, for you will not accomplish 
anything. In most instances we leave some morphine in our patient's 
possession, as he is apt to be nervous and panicky without it. It is a 
comfort to him to know that if he is too hard pressed he has the means 
of relief in his possession; and animated by that knowledge, he will ask 
himself the question whether he is really suffering more than he can 
endure, and conclude that he will '" stick it out" a few hours more, then 
another hour, and another, until the crisis has passed; he falls asleep 
and awakes to find that the dreaded ordeal has passed, and that he has 
gone through it by the aid of his own will. And so he has learned the 
lesson of self-confidence; and in this we see the beginnings of that only 
true cure, that lies in the restoration of the power of manly self-control. 

"Resist the devil and he will flee from you, " says the great Book; and 
true it is that the tempter is but a cowardly, bully when he is faced boldly. 

But to some persons the possession of morphine is not a comfort 
but an annoyance. The thought of it will keep them awake; they will 
lie in bed thinking about it until the desire for it is too strong to be 
resisted. They are like the toper who would not buy a jug of whisky 
to carry him over Sunday, because he could not sleep if he knew there 
was whisky in the house. Such men voluntarily place their morphine 
in our hands and say they will feel easier if they know they have none 
and can get none. 

Besides this, the urine should be tested every day, that the surrep- 
titious taking of the drug may be at once detected. Drop a grain of 



THE MORPHINE HABIT 771 

Merck's neutral chloride of iron into the urine; the depth of the green 
coloration will show the quantity of morphine that is being eliminated. 

If, however, the powerful influence of hypnotic suggestion can be 
exercised over the patient, the course will be easy and agreeable; if not, 
there will surely be a struggle, an ordeal through which the patient must 
pass to win his freedom. Be not deceived; there is no shirking the con- 
flict. If the patient declares he has been cured without suffering, the 
curative influence has been suggestion, or he is still taking morphine, 
or else he lies. We have had abundant experience of each. 

The next step is to go over your patient thoroughly and see what 
kind of a man he is. Examine him as to his general physique, and then 
review every function of his organs. Quite often you will find a state 
of debility that requires reconstructives at once; and it is best to begin 
this treatment before seriously attacking the habit. Add to this efficient 
treatment of anything that may be found out of order, no matter how 
inconsequent it may appear. We can give no specific directions here; 
the skill of the physician alone can guide him. 

In every solitary case the bowels are packed with feces. Give ten 
grains of calomel or twenty of blue pill, followed by saline laxatives, 
repeated every hour or two until the bowels have been thoroughly 
emptied. An enema or two of hot water, passed up beyond the sigmoid 
flexure, will aid materially. 

Having emptied the alimentary canal, keep it clear by the cathartics 
mentioned, and render it aseptic by the use of intestinal antiseptics you 
prefer. From six to twelve of the W-A tablets daily will accomplish 
this object, and these must be continued throughout the whole course 
of treatment, giving just enough to render the stools inodorous. 

Keep the patient as quiet as possible, preferably in bed, as the distress 
is brought on or aggravated by exercise. Let the food be such as the 
patient prefers, light, nutritious but digestible, with an abundance of 
fresh fruit juices, and of salt. Have a capable attendant ready at all 
hours of the day and night to give a hot or cold bath, with massage, 
whenever the patient's restlessness demands it. Pain, burning and 
nearly all the real suffering, went out when intestinal antiseptic was 
instituted, but there remains the nervousness, sense of " goneness," the 
"new" or naked sensitive feeling, which is largely suggestive and is best 
relieved by hydropathic measures. 

The cold bath is best reserved until the crisis is over when the patient 
has had no morphine for forty-eight hours. Then the cold shower, 
douche, plunge or pack will bring about reaction better than any other 
remedv. 



772 THE MORPHINE HABIT 

The cold bath should be so administered as to bring about reaction 
— a quick plunge into the tub and instantly out again, followed by brisk 
rubbing, slapping, hot drinks, such as capsicum tea, and wrapping in 
warm blankets. The first drug-free sleep usually comes after such a 
bath. 

The morphine is to be reduced as rapidly as the patient's condition 
allows. Young and sound individuals, and the self-indulgent whining 
weaklings, should be cut off short; but with older or broken-down men, 
one must be most careful and most merciful. 

When the reduction begins to be felt, one or another of the special 
agents may be employed to mitigate the suffering. Codeine is hardly 
of value except where its use is gradually substituted for that of mor- 
phine. The same may be said of narceine and cannabis indica. The 
bromides interfere with digestion, causing an extraordinary fetor of the 
breath, so that they do more harm than good. 

Physostigmine gives the most perfect relief in some cases, especially 
those showing passive congestion of the face, with dilated capillaries. 

Strychnine relieves others singularly, especially when the relaxation 
and debility are great. This drug must be given in doses that will 
produce their effect, no matter how large; but some cannot bear more 
than gr. i-ioo at a dose. 

Quinine, in doses of gr., 10-40, daily, also relieves some cases; but we 
have not been able to specify them. 

To secure sleep we employ hyoscine, gr. 1-500 — 1-100; after two 
days substitute passiflora, lupulin, cypripedin or scutellarin, caffeine 
valerianate often answers well. 

The heart must be watched constantly and any evidence of weak- 
ness or irregulartiy met by digitalin, sparteine or cactus, in sufficient 
doses. These drugs then produce sleep better than the regular 
hypnotics. Pettey gives sparteine in two-grain doses by hypodermic. 

Never give a second dose of hypnotic the same night; if you do, the 
patient will never again fall asleep till he has had his second dose. 

Change the hypnotic nightly. 

As general tonics, hydrastis, cinchona, avena, passiflora, arsenic and 
iron may be variously combined. 

Pettey has called attention to the great value of sparteine when given 
hypodermically in doses of not less than two grains to an adult. This 
exerts little tensive force on the blood-vessels but aids the heart mate- 
rially. Hyoscine has been advised in doses of gr. 1-200 to 1-50, repeated 
every half hour so as to keep the patient stupefied till the withdrawal 
period has passed. We have had no experience with this method and 



LEAD POISONING 773 

will have noiic. A> we have attempted to show, the principle on which 
it is based is an error, and the method is too dangerous for us. Hyoscine 
as a hypnotic in suitable doses is our main reliance, but this continuous 
stupefaction is only a variation of the chloral method herein described. 

The approach of a relapse is heralded by dyspnea, aches, and 
especially by subnormal temperature. We regard this as evidence that 
intestinal autotoxemia is present and that metabolism is deficient. Clear 
the bowels by the usual means and give the patient nuclein solution up 
to a dram each twenty-four hours, to arouse the vital powers and incite 
metabolism. This remedy should be given throughout the treatment, 
hypodermically, in ten-drop doses every four hours, as it greatly 
relieves the withdrawal symptoms and sustains the patient. If the 
patient has used cocaine also, we usually combine brucine gr. 1-40 to 1-5 
with each dose of the nuclein, brucine sustaining like strychnine and 
being also a powerful local anesthetic. 

Relapse is most apt to occur about seven months after the cure. 
Constant, intelligent supervision of elimination is the best means of 
prevention. Strongly neurotic patients need to live under medical advice, 
and often a course of neuro-lecithin is of benefit, with strychnine and 
caffeine valerianate for the props, if some are unavoidable. These 
neurotics are always troublesome problems, but whenever the world 
adopts Spartan methods of dealing with them, physicians will become 
superfluous. 

LEAD POISONING 

The persistent absorption of small daily doses of lead causes grave 
disorders. The muscles are atrophied, pale-yellow, the connective 
hyperplastic. Arteriosclerosis develops. Parenchymatous neuritis 
affects the peripheral nerves, with degeneration of the ends in the mus- 
cles. This process may extend to the anterior spinal roots, less marked 
as the periphery is remote. Cerebral lesions are limited to the vessels, 
with slight meningitis, connective hyperplasia and capillary hemor- 
rhages. Cirrhosis affects the liver and kidneys. 

Etiology: — There is a difference in the susceptibility of individuals; 
women are more liable, but the occupations of men expose them more. 
All workers in lead are liable, especially during their early years when 
they are heedless. The metal is most frequently carried to the mouth 
by the hands, workers neglecting to wash before eating or helping 
themselves to tobacco with paint-covered fingers. Among lead-users 
Anders enumerates painters, plumbers, lead miners, sheet-lead rollers, 



774 LEAD POISONING 

potters, type founders and setters, shot makers, glass grinders; dress- 
makers, lace weavers and other operatives who bite off the ends of lead- 
dyed threads, and calico printers. Many accidental contaminations 
of food have been reported. Flint's celebrated case was an epidemic 
that resulted from a miller who had mended holes in his millstones by 
filling with melted lead. Stewart unearthed a widespread prevalence 
of lead poisoning in Philadelphia from the use of chrome-yellow to give 
a rich color to buns and other bakery products. Cheap candies are 
sometimes colored with saturnine dyes. Tobacco sold in lead wrappers 
is a danger; lead water tanks or pipes, milk cans, and other receptacles 
for foods may be sources of poison, especially if the contents contain 
acids that will dissolve the lead. 

Lead poisoning usually occurs through the mouth and stomach, less 
frequently by the lungs, rarely by the skin. Hair dyes sometimes cause 
it. The metal is deposited mostly in the nerves, muscles and liver. 
It is eliminated by the kidneys, slightly by the bile and saliva, very 
slightly by the skin. Unless hastened by treatment elimination is 
exceedingly slow and never perfect. 

Symptoms: — These are slow in development. Anemia gradually 
appears, the red cells and hemoglobin decreasing pari passu, leucocytes 
multiplying, the former pale and degenerated, while nutrition is 
impaired. A lead line appears along the margin of the gums, of lead 
sulphide, if the gums are slightly separated from the teeth (Gowers). 
Bluish patches are sometimes seen on the mucosa. Severe attacks of 
colic occur about the navel, with griping; the abdomen is retracted 
and hard, the bowels constipated, vomiting is usual; a dull pain is con- 
stant with paroxysms of severity during which the pulse is- tense and 
the heart weak. 

Lead palsies, acute, subacute and chronic are common; most fre- 
quent in the forearm extensors, causing wristdrop. Muscular tremors 
also occur, coarse or fine, beginning in the hands and aggravated by 
voluntary movement. Muscular cramps are common, about the joints, 
with anesthetic patches occasionally. Cerebral symptoms are plen- 
tiful, such as delirium, coma, aphasia, neuroretinitis, convulsions, hemi- 
plegia, amaurosis, hysteria, and mental derangements. Hemianopsia 
has been noted. Severe headaches are common. Gouty attacks may 
occur. Symptoms in time result from the renal cirrhosis, cardiac hyper- 
trophy and arteriosclerosis. The urine shows the presence of lead, 
which will be deposited on a strip of magnesium laid in it. The 
addition of ammonium oxalate, i part to 150, facilitates this test 
( Abram) . 



LEAD POISONING 775 

Diagnosis: — This is easy if the history indicates lead, but in many 
instances there is nothing to direct attention to the possibility of the 
cause of the symptoms. When Stewart had announced the discovery 
of lead in buns many physicians recognized among their patients cases 
of saturnism not previously suspected. The excitement died down, 
and very probably the colors are now used as freely as ever, and will 
be until some one rediscovers this cause of many obscure ailments. 
When the wristdrop, blue line, colic and cachexia are recognized the 
diagnosis is obvious. In less marked cases an examination of the urine 
for lead will reveal the difficulty. Punctate basic degeneration of the 
red cells is a characteristic. 

In the earlier stages the prognosis is good; the material lesions of 
the kidneys, heart and vessels are permanent. Profound paralysis 
with reaction of degeneration and primary muscular atrophy, the severe 
cerebral cases, offer a bad outlook. 

Treatment: — Lead poisoning in the arts is to be prevented by 
instructing workers on the necessity of keeping the lead out of their 
mouths and lungs, by scrupulous cleanliness, and refraining from chew- 
ing tobacco until it can be handled with clean hands. Respirators are 
useful to intercept lead-contaminated dust. Ventilation and means 
of carrying away the dust are better, since the respirators soon become 
so clogged that the careless workman casts them aside sooner than 
spare time for constant changes. The use of sulphuric acid is a good 
preventive, changing the lead to an insoluble sulphate. Milk is also 
advised for this purpose. 

The iodide of lead being readily soluble, the use of iodine is recom- 
mended to carry the metal out of the system When lead has been 
deposited, its solution is accomplished very slowly, and persistence in 
treatment alone offers a chance of success. The first effect may be 
a return of active toxic symptoms, as the dissolved lead is taken up by 
the circulation. The most active forms of iodine are preferable, such 
as calx iodata, which parts with its iodine more readily than do the 
fixed iodides. The doses should be moderate at first, and at the appear- 
ance of saturnine symptoms be suspended for a time. Ten grains a 
day in divided doses may be assumed as the average adult dose. The 
effect will be enhanced by keeping up elimination so that the lead 
iodide may be promptly ejected from the body. Warm baths with 
sweating, cholagogs, pilocarpine every other evening, and especially 
free flushing of the kidneys with saline solution thrown into the colon, 
aie efficacious. As a cathartic alum has proved effective, its astringency 
relieving the paresis to which the constipation is due. 



77^ ARSENIC POISONING 

The treatment of lead colic calls for morphine and atropine hypo- 
dermically to assuage pain and relax spasm; saline laxatives, with 
warm colonic flushes, and alum or sulphuric acid to render lead still 
in the alimentary canal insoluble. 

Anemia requires iron, paralysis strychnine and electricity, vascular 
tension veratrine — and ever and always, elimination. 

ARSENIC POISONING 

Degenerative neuritis affects the peripheral nerves and the anterior 
horns of the spinal cord. The chronic form is here considered. 

Etiology. — Neurotics, the numerous class who constantly feel the 
need of something to bring them up to the sense of healthy well-being 
may take arsenic for this purpose. Many women take it for its sup- 
posed value in improving the complexion. In the arts arsenic poison- 
ing affects miners of arsenic-bearing ores, dyers, wall-paper makers and 
handlers, artificial-flower handlers, shot and glass workers, and taxider- 
mists. Some persons are very susceptible to arsenic and show paralysis 
after taking it medicinally for brief periods. Persons living in rooms 
adorned with arsenic papers or carpets, or working with toys, orna- 
ments or curtains impregnated with arsenic colors, are occasionally 
found to be suffering this intoxication. Special susceptibility prob- 
ably exists, as practically all modern wall papers are tinted with arsenic. 

Symptoms: — Dryness and irritation occur in the eyes, nose, throat 
and larynx; gastrointestinal catarrh arises, with anorexia, nausea and 
diarrhea; anemia and emaciation appear; the eyelids are irritated; dis- 
comfort is experienced in the stomach; the hair grows thin; dysenteric 
attacks occur, and sometimes numbness or tingling in the extremities. 
The skin may show dark pigmentation or various eruptions, generally 
of the scaly forms. The kidneys are irritated and blood and albumin 
appear in the urine. 

Multiple neuritis develops, first in the leg extensors and peronei, 
later in the arms; contractions occur in the legs, tremors in the arms. 
Headache, vertigo, melancholy and nervous unrest sometimes are pres- 
ent. Remarkable toleration is manifested by some individuals, and 
in some it causes a singularly beautiful wax-like complexion, plump- 
ness and bright eyes adding to the cosmetic effect. This is quite except- 
ional, and as a rule the use of this drug does not benefit the appear- 
ance but rather imparts a mulatto tint to the skin. 

The diagnosis is easy when the existence of the trouble is suspected. 
Chemical examination of the urine detects the poison. The prognosis 



MERCURIAL POISONING 777 

is good when the case is early recognized and the patient can be 
removed from arsenical influences. 

Abstinence from arsenic, removal of toxic papers, carpets and cur- 
tains are followed by improvement. Calx iodata, ten grains a day, 
will dissolve the poison out of the tissues and free elimination will carry 
it out of the body. Remedies are to be applied as the symptoms dic- 
tate. When fatty degeneration has progressed it may possibly be 
arrested by the use of neurolecithin. 

MERCURIAL POISONING 

The continued ingestion of mercury causes toxic manifestations, 
varying with the susceptibility of the patient. The effect of the metal 
is manifested in the mouth and stomach, later in the kidneys, and prob- 
ably in the brain. 

Etiology: — The excessive administration of mercury is now rare. 
Its vapors are inhaled by miners, smelters, mirror silverers, and those 
w r orking with amalgams, barometers, thermometers, felt hats, vermilion 
pigments, and artificial teeth. The poison enters the body through the 
alimentary canal, the lungs or the skin. Women and children are more 
susceptible than men. The mercury exists in the tissues as an albu- 
minate. 

Symptoms: — The teeth feel too long and are tender, the gums swell, 
catarrh of the mouth occurs which may proceed to ulceration and loss 
of the teeth or even necrosis of the maxillae. The tissues generally 
show the solvent action of mercury, exudations and the debris of inflam- 
mations are absorbed, slight fever occurs, all the secretions and excre- 
tions are increased, and a general stimulation of the functions, bodily 
and mental, occurs. Tremors follow and paralytic symptoms. Fine 
tremors appear in the tongue and lips, growing coarser, extending over the 
voluntary muscles. They cease during sleep and are worse on motion. 
Speech is affected. Irritability exists, aphasia may occur, or hemiplegia, 
hemianesthesia, peripheral neuritis, with pareses, joint pains, various 
cerebral symptoms, insomnia, hallucinations, delirium, coma, convul- 
sions, headache, loss of memory or some form of mental derangement. 
Albuminuria or anascarca may follow. Children born of salivated 
mothers are apt to be weak and ill-developed, falling prey to tuberculosis 
readily. 

The diagnosis is easy when the history is perfect. Progressive general 
paresis, disseminated sclerosis and paralysis agitans are to be differen- 
tiated. Recovery usually ensues if the poison is removed. 



778 PTOMAINE POISONING 

Treatment: — Stop the mercury; eliminate what has been taken, by 
the use of calx iodata as described for lead and arsenic. Mercury is 
more readily dissolved out, yet time must be allowed for complete 
eradication. Atropine checks the salivary symptoms. Hydrastine 
forms an excellent lotion for the mouth, a grain in an ounce of water 
used frequently. Tonics may be given at once with the iodine; in fact 
iron iodide is useful, the iron restoring the blood while the iodine is 
carrying aWay the poison. The paretic manifestations call for strych- 
nine in full doses and various applications of electricity. Sometimes 
when any tissue shows the destructive effects of mercury, and it is an 
even thing if the vitality will or will not be retained, local applications 
of neuclein solution will turn the scale in favor of the vital forces and 
save the imperiled structures. 

PTOMAINE POISONING 

The general use of canned meats and other foods has vastly increased 
the number of instances of poisoning from these articles when in a 
state of decomposition. Even when the proprietors and managers of 
packing houses do their best to prevent the packing of unwholesome 
articles, there is always the danger that employees who have permitted 
foods to spoil will endeavor to conceal their carelessness by slipping the 
decomposing material past the inspectors. The result is a general 
suspicion of canned foods that greatly interfers with the use of them, 
and limits the application of a method of preserving surplus foods and 
transporting them safely, that would else be one of the greatest boons 
humanity has received from modern science. Famines would other- 
wise be a thing of the past, for in all cases there is somewhere an 
abundance of food to spare, if it could only be preserved from spoiling 
until transferred to the region of scarcity. But this golden ideal is dis- 
sipated — by the carelessness of employees and the greed of employers. 
No intelligent man ever opens a can of meat or fish without scanning 
it for evidences of decomposition, or partakes of it without some appre- 
hension. 

Foods may be toxic through infection of the animal or plant from 
which they are derived, by the access of microorganisms before the 
food is eaten, or by the action of toxicogenic organisms after is has been 
eaten. Tuberculosis, anthrax, glanders, trichina, pleuropneumonia and 
other diseases of animals are transmissible to man in the infected flesh. 
Meat and milk carry diphtheria and typhoid fever absorbed from their 
surroundings, or in them toxins develop from the action of germs not 



PTOMAINE POISONING 77<) 

themselves directly pathogenic. Some saprophytes can live in the 
body and acquire noxious powers there (Novy). Toxins developed 
in foods by saprophytes are termed putrefactive alkaloids; bacterial 
proteid products are toxalbumins or toxalbumoses. All may be absorbed 
from the alimentary canal. 

The summer diarrheas of infants are due to milk infected by sapro- 
phytic products, among which is tyrotoxicon. This does not lose its 
toxicity by being passed with the milk into cheese or any articles of 
food prepared from milk by cooking. It causes acute gastrointestinal 
inflammation, constriction of the fauces, headache, convulsions, chilli- 
ness with great depression and purging. If continued, exhaustion 
supervenes, and subnormal temperature, collapse, coma and death. 
No antidote is known. The vomiting is relieved by minute doses of 
calomel, gr. 1-20 to 1-10 every half hour, with a grain of some mild 
soothing agent, like bismuth or chalk. Follow with a sweep-out with 
castor oil or similar laxative, and disinfect the bowel with the sulpho- 
carbolates in sufficient doses. Atropine hypodermically is the remedy 
for collapse and excessive discharges, and the weakness may require 
strychnine in doses suited to the age and the need. Flushing the colon 
with zinc sulphocarbolate solution, a grain to the ounce, aids elimination. 

Tainted meats are not rendered innocuous by cooking. They cause 
infections only when not thoroughly cooked, or ptomaine poisoning 
whether raw or cooked. In the latter case gastroenteritis results, with 
violent retching and vomiting, intense colic, purging of choleraic type, 
fever, weak and rapid pulse, nervous and muscular prostration, cramps 
in the calf muscles; and in extreme cases the temperature becomes sub- 
normal, great exhaustion is manifest, with dyspnea, somnolence, sore 
mouth, collapse and even death. There is sometimes a close similarity 
to arsenic poisoning, but Harrington mentions three points of differ- 
ence: In arsenic poisoning the patient swallows because of pain; the 
pupils are not dilated or the muscular prostration as extreme as in 
ptomaine cases. 

Fish and shellfish frequently cause poisoning. Some of these con- 
tain toxic principles, others are themselves affected with disease which 
is transmissible with their tissues to the eater. The sturgeon and the 
salmon are sometimes diseased, as eaten in Russia. Brieger discov- 
ered mytilotoxin in certain mussels which cause epidemics occasion- 
ally. The conditions that cause these foods to be toxic at times are not 
understood, since the symptoms may occur after eating them when 
undoubtedly undecomposed. Generally, however, the trouble may 
justly be attributed to canning the fish after decomposition has com- 



780 PTOMAINE POISONING 

menced. The symptoms are often those already described as caused by 
bad meats. Sometimes the toxins affect the brain, causing convulsions, 
paralysis, etc. Symptoms of collapse accompany and terminate the 
malady. Irritations of the skin occur in less serious cases, as urticaria, 
pruritus, erythema, etc. Grave cerebral symptoms or collapse are seri- 
ous prognostics. The treatment is that described below. 

The use of rye containing ergot has resulted in serious symptoms. 
This happens in lands where cultivation is backward, as in Russia and 
Spain, and where the people are so poor that even diseased grain must 
be eaten as preferable to no food at all. The symptoms differ accord- 
ing to the proportions of the different active principles present. If cor- 
nutine predominates we have the neural group, debility, tingling in the 
extremities, headache, followed by cramps and contractures, convul- 
sions, delirium, dementia in chronic cases, and if death does not ensue 
a slow recovery diversified by anesthesias, persisting contractures and 
muscular atrophy. Ataxic symptoms sometimes occur. Pregnant 
women abort. If sphacelinic acid be in excess the gangrenous type 
is seen. Dry gangrene of the fingers and toes follows pains, formica- 
tion, anesthesia and coldness. Fever may attend the separation. 
Septic pneumonia may end the case. Some epidemics are quite fatal. 
No treatment has been devised further than stopping the use of the 
diseased grain. Whether glonoin, veratrine or atropine would unlock 
the strangling grasp of ergot on the blood-vessels does not seem to have 
been tested. The nervous type calls for the most vigorous elimination, 
the forces being sustained by strychnine and perhaps by zinc phosphide. 

Pellagra occurs in Italy from the use of diseased corn meal. Micro- 
organisms attack the fresh damp meal and develop ptomains. Its 
use causes debility, digestive disturbances, nervous unrest, and diar- 
rhea. Erythema follows with pain and desquamation of the epider- 
mis. Nervous symptoms sometimes predominate, headache, mental 
aberrations, delirium, spasms, pareses and suicidal impulses. Repeated 
attacks may result in idiocy or profound cachexia. Fatty degeneration 
and ulceration have been found in the intestines and some changes in 
the cord. No special treatment has been devised. 

Three varieties of chick-pea or vetch cause, when eaten, stiffness of 
the legs and transverse myelitis, sensory and motor paralysis following. 
Contractures and exaggerated tendon reflexes may remain after the 
acute symptoms subside. Chronic cases may die in paralysis. The 
malady is known as lathyrismus. 

Two poisons exist in mushrooms: muscarine, which is present in the 
fly amanita, and phallin, which is also found with muscarine in the 



OBESITY 781 

amanita phalloides. Phallin acts like serpent venom and causes pro- 
found vasomotor paralysis of the abdominal vessels, the blood collecting 
in them till fatal synocope results, and also causes liquifaction of the 
blood corpuscles. There is no known antidote, but strychnine should 
be pushed to toxic effect and this sustained. Phallin is a toxalbumin 
and is destroyed by cooking. Muscarine causes cardiac debility, free 
vomiting and serous diarrhea, both absolutely devoid of distress or pain. 
The face is marble-white and cold, extremities cold, pulse feeble and 
muscles weak, but the mind is clear and there is a remarkable absence 
of vertigo and faintness, as well as of nausea, considering the other 
symptoms. Muscarine is completely antidoted by atropine, which 
greatly excels the former in power. Muscarine passes out of the body 
by the kidneys so rapidly that it is very difficult to obtain a therapeu- 
tic action from it unless given in full dose intravenously. Death from 
muscarine could not occur after any dose if atropine is given in suffi- 
cient quantity. As phallin is destroyed by cooking, therefore it seems 
to follow that death from well-cooked mushrooms of any variety is 
impossible if atropine be in reach. The green russula and at least 
one boletus are toxic in less degree, and possibly other unrecognized 
fungi. It is safe for the lover of these delicious plants to reject any 
except varieties he has classified and knows to be safe. The true 
mushroom crank will eat all he does not know to be unwholesome, 
until he gets a lesson. 

The variety that caused the symptoms above described was as large 
as a dinner-plate, and did not show the characretistics of the fly amanita 
though the effect proved the relationship. 

OBESITY 

The increase of fat becomes a disease when it commences to inter- 
fere with the functions of the body. Excessive weight is less menac- 
ing to longevity than insufficient weight, since life insurance companies 
permit a much greater percentage of excess than of deficiency in accept- 
able risks. The fat is increased in its normal locations and the internal 
organs are overlaid and infiltrated with it. In the plethoric the fat 
globules are larger than in the anemic. The heart is especially over- 
laid and infiltrated. The arteries are fatty, with patches of inflamma- 
tion on the intima, the veins varicose. The lungs become congested 
and edematous as the heart weakens, and as well as the liver, kidneys, 
etc., are infiltrated with fat. The stomach is often catarrhal and 
dilated. 



782 OBESITY 

The malady represents a disorder of metabolism and is often 
hereditary. Climate, habits, occupation, age, sex and temperament 
influence its development. Warm, low, moist climates, indolent habits, 
sedentary occupations, advancing age when the activity of youth is dis- 
continued; in women marriage and childbearing, sometimes the meno- 
pause, and an easy philosophic temperament, favor obesity. Certain 
races seem predisposed, but this is probably due to the above influences. 
Direct causes may be found in excessive use of water and other bever- 
ages, an excess of fat-making elements in the food, alcohol, deficient 
exercise, and the enforced idleness following an accident. 

Symptoms: — The advance of weight renders exercise more difficult, 
causes shortness of breath, in plethoric persons redness of face on exer- 
tion, in the anemic pallor with palpitation, weak pulse, somnolence and 
dizziness. The heart exhibits the signs of fat encumbrance. Many 
obese persons consume very little food, but they are apt to eat fast and 
masticate but little, washing the food down with much cold water. 

The fat bear diseases and surgical operations badly, and are prone 
to excessive fever on slight occasion. The liver is enlarged, with soft 
edges. Pulmonary congestion induces a catarrhal tendency and cough 
on slight exertion. They sweat readily, excrete much uric acid, drink 
hugely, the bowels may be easily moved or show diarrhea, and the 
sexual function is often weakened or lost. Women are sterile, amenor- 
rheic, with uterine derangements and frequently prolapse. The meno- 
pause is a season of distress. Intertrigo, eczema and pruritus are com- 
mon, while hernia, asthma, respiratory catarrhs and inflammations, 
edema, arteriosclerosis, albuminuria, glycosuria, angina, Cheyne- 
Stokes breathing, apoplexy and coma are features of some portion of 
the course. 

The diagnosis is as to the position and the effects of the deposits. 
The prognosis depends on the degree, the effects, the impairment of 
the heart and other vital organs, associated conditions, and the means 
and tractability of the patient. Obesity in itself threatens longevity; 
the habits and tendencies that lead to it are still more to be dreaded. 
The earlier in life it begins, the greater the danger and the difficulty in 
dealing with it, especially when heredity is decided. Beer drinkers' 
obesity is the most to be dreaded as the liability to sudden death is 
great, from the structural disorder of the cardiac muscle. Muscular 
overstrain is apt to cause apoplexy in the plethoric, syncope in the 
anemic. Exposure to excessive heat is dangerous to either class, the 
plethoric especially. Any intercurrent malady is likely to prove fatal 
to these persons. Even the plethoric bear venesection badly. 



OBESITY 783 

Von Noorden suggests that before beginning treatment it would be 
well to determine whether any treatment should be undertaken, and 
if so, whether we should attempt to reduce the fat already deposited 
or simply restrain the further deposit. Patients desire reduction from 
cosmetic considerations, or oppose the suggestion from the mistaken 
idea that a reduction process is necessarily weakening or endangers life. 

Very advanced forms require treatment to prevent the consequences 
if the malady goes on. Before the twentieth year it is best to arrange 
the diet so as to prevent further increase in weight, and occasionally 
enforce a closer abstinence for a month only. In the aged, reduction- 
cures almost without exception accelerate senile decay and the decline 
of strength and functional activity. (Von Noorden.) 

When the excess over the average for height is not more than 30 to 
50 pounds, the case is more amenable to treatment. If no discomfort 
is caused and the growth is not increasing it may be wise to let it alone. 
Still, it is a source of danger when intercurrent disease appears and 
throws a strain upon the heart. The objection to interfering when age 
has advanced holds good here also, and with younger subjects the 
reduction should be gradual and carefully watched. A further 
increase should be prevented and the occurrence of obstructive symp- 
toms renders reduction imperative. This is also the case when the habits 
and tendencies of the patient are such as to indicate that he will not so 
live as to prevent further increase of the difficulty. 

The treatment may be opened by a quick reduction of 10 to 15 
pounds, without injury; but the crux of the matter is reached by the 
prolonged action of the slower method, the more or less permanent 
restrictions which are far more difficult to enforce. Instead, the month 's 
reduction is likely to be followed by an indulgence that soon restores 
the lost weight with goodly interest. With most patients the desider- 
atum seems to be a remedy that will reduce weight safely without 
requiring any increase of exercise or forbearance in the way of eating 
and drinking. For these, Von Noorden advises monthly courses 
of treatment at varying intervals, followed by systematic exercises and 
skin stimulation in the intervals, with such restrictions as the patient 
can be induced to submit to. Much better results will be secured in a 
sanatorium than at the patient's home; and the laudable desire to get 
the worth of one's money indicates the wisdom of making the charges 
as high as possible. The regimen there enforced should teach the patient 
the better methods of living that may be practised after returning home. 

Slight obesity, overweight of 10 to 30 pounds, does not require 
reduction methods but simple regulation of the diet, etc., so as to pre- 



784 OBESITY 

vent further increase. Whether the desire of women to retain their 
physical attractions can be justly attributed, to " vanity," as Von Noorden 
assumes, might be ascertained by inquiring how much of a woman's 
success in her life-work depends on her looks. Since the regimen that 
reduces weight makes also for health and longevity, the physician here 
finds his opportunity to inculcate the lessons of hygiene, with prospects 
of being obeyed. Slow reduction tends to remove fat uniformily, while 
the rapid processes do not apparently affect abdominal deposits. The 
loss of fat may not be an unmixed benefit, for women may suffer from 
constipation, hernia, gastroptosis, malposition of the kidneys or the 
uterus, or gallstone colics may begin, the loss of fat having exposed the 
diseased organ to pressure. Abdominal massage may increase the loss 
at this point, and is specially valuable when intestinal atony has followed 
the reduction, as is frequently the case. 

Questions of Complications;— Diseases of the heart or vessels, and of 
other parts, that also throw an increase of labor upon the heart, so that 
its strength is below the requirements for exertion made upon it, call 
for the reduction of fat. Every pound of useless fat increases the 
necessary and unavoidable work of the heart. Since we cannot hope 
to cure organic lesions it is all the more essential for us to lessen the work 
of the heart until we reach the balance between its powers and its labor. 
In fact, the presence of some obesity in heart-cases renders their prog- 
nosis more favorable. This matter is fully considered in the treatment 
of heart-diseases. Von Noorden advises that after ten pounds have 
been lost the diet should be relaxed sO as just to hold the weight for a 
month; and then again reduced. Assistance is obtained from skin stimu- 
lation by cold baths, salt rubs, sitzbaths, prescribed exercises,- douches 
and carbonated mud baths; and the process should be continued until 
the normal weight has been restored for the height and age. 

To the patient with interstitial nephritis obesity is as dangerous as 
to him with heart-disease. The removal of surplus fat from chronic 
bronchitics markedly benefits these patients, while the limitation 
of thoracic space by fat deposits may render an ordinary bronchial 
attack fatal. Similar benefits follow reduction methods in chronic rheu- 
matics, and other remedies will after reduction produce more decidedly 
beneficial results. Gout and obesity often coexist, and their treatment 
harmonizes. Such patients can take larger quantities of meats with 
impunity if they also take an abundance of vegetable foods. Of 
the three conditions, obesity, uricacidemia and the lame heart, the 
latter is the factor that will govern the methods of treatment to be 
adopted. 



OBESITY 785 

In a number of affections in which locomotion is impaired a reduction 
of the fat will enable the patient to get about with more freedom. 
Exercising and training the muscles will often be of decided benefit in 
addition. The paralyses come under this head, and other nervous 
affections may also be thus benefited, such as sciatica and other neur- 
algias, and hysteria. The relief that ensues is not easily explained, 
unless we adopt the view that regards neuritic symptoms as evidence 
of the leakage of nerve force, the insufficiency of the supply being mani- 
fested by that portion of the organism least able to attract to itself its 
full share. The heart may show no evidence of unusual strain because 
it robs some nerve (the brachial plexus perhaps), of part of its supply. 
Reduce the weight, lessen the demands upon the heart, and the lessened 
requirements of the selfish organ leave more for the suffering, starved 
nerve. At least this is a very convenient means of explaining many 
phenomena, better than the "reflex" theory, which is in fact no explana- 
tion at all. 

A different state of affairs faces us in diabetics. They bear reduction 
methods poorly, and if the fat is not excessive, had better be let alone. 
But when the fat endangers life, and when the weakness of the heart 
is a perilous symptom, the fat must be reduced to a safer limit. The 
intermittent method is applicable, taking away two or three pounds by 
a limited diet, and this in about a month; repeating every three months. 

How as to consumptives? There seems danger that the fattening 
of these may be carried beyond the bounds of reason. Obesity carries 
too many disabilities to render it advisable to persons whose hygiene 
requires such delicate adjustment. A generous fatness is desirable but 
not more. The reduction in such cases is a problem of much impor- 
tance, the risks being great. 

Reduction may be accelerated by adding the use of thyroid extract, 
in moderate doses. But in the vast majority of cases the method above 
described will reduce the weight quite as fast as is safe. How T ever, the 
patient may urge a rapid reduction, and great as may be the fame 
thereby acquired by the doctor, there is rarely a case that is not best 
managed by limiting the wasting to a pound a week. 

The effects of phytolaccin may not be evident until it has been taken 
for one to three months, when an active wasting may set in, and continue 
after the drug has been discontinued. We do not approve of any prep- 
aration of this drug for use by itself. As an ingredient of remedies for 
the reduction of superfluous and encumbering fat it is useful, but 
when given alone its effects may be manifested suddenly and with 
alarm 'ng vigor. 



;86 SUNSTROKE 

SUNSTROKE 

Under this designation two forms of disease are included, both in a 
measure due to exposure to the rays of the sun when excessively ardent, 
but differing in pathology, symptoms and treatment. 

Pathology: — Rigor mortis and decomposition occur earlier than 
usual. There is engorgement of the brain and cord, membranes, 
lungs, spleen, conjunctiva; the blood dark and fluid, the red cells de- 
formed. Extravasations of blood are found in the skin, serosa, and 
about the sympathetic ganglia, vagus and phrenic nerves. The left 
ventricle is rigidly contracted, the right auricle dilated. Van Gieson 
found acute parenchymatous degeneration of the neurons of the 
whole cerebrospinal axis, which he attributed to a species of auto- 
intoxication. 

Etiology: — The persons who out of the population fall victims to 
sunstroke are those who have become debilitated by disease, privations, 
unsanitary surroundings, over-fatigue or emotional exhaustion, alcoholic, 
venereal or dietary excess. Men are more liable than women. Auto- 
intoxication from fecal absorption or renal, cutaneous or hepatic defi- 
ciency of activity, renders men exceedingly liable. To such persons, 
exercising under direct rays of the sun with temperature exceeding 90F., 
when the humidity is high, , or in closely confined and very hot places, 
there is danger of sunstroke. 

Heat exhaustion occurs in fat elderly persons, who drink ice-water 
excessively, perspire freely, and eat little because their stomachs are 
disabled by the icy floods. Their "sunstrokes" are syncopes. 

Symptoms: — Heat apoplexy is rare. The patient may have warnings 
such as dizziness, chromatopsia, throbbing headache, dyspnea, or 
cessation of sweating. He may fall while at work, have convulsions, 
and die with heart-failure. More frequently the effect is not so profound, 
but the patient is restless, with cramps in the abdomen and oppression 
of the chest, vomiting, intense headache, flushed face, the pulse full, 
bounding and hard, respiration stertorous, arteries pulsating visibly, 
pupils contracted and bladder irritable. The skin is dry and hot, 
sometimes showing petechias, tongue white, temperature moderately 
high, normal or subnormal, but sometimes hyperpyretic. Wild delirium 
is an unusual feature. If the case progresses the coma deepens, the 
pulse weakens, and Cheyne-Stokes respiration appears before death. 
If recovery ensues the fever subsides and consciousness gradually returns. 
The "mousey odor" described as sometimes present is simply an evidence 
of toxemia. 



SUNSTROKE' 783 

More frequently to the symptoms above described is added hyper- 
pyrexia in which the temperature rises to an unprecedented degree. 
The writer has registered 113 F., but this figure has been exceeded. 
Death is not long delayed if the brain is not quickly relieved from such 
a strain. 

Among prodromes noticed — which may or may not signify the 
approach of sunstroke — are anorexia, growing debility, abdominal cramps, 
nervous unrest and temper, vertigo, blurred vision with disturbed color 
sense, bursting headache, irritability of the bladder, and most ominous 
of all, stoppage of sweating. Such symptoms spell danger especially 
to the man whose blood-vessels are diseased, kidneys or liver deranged. 
The patient may go on about his occupation in a mechanical, automatic 
manner for some hours before the stroke occurs with symptoms as above 
described. Hyperpyrexia is present at the start, clonic spasms alter- 
nate with muscular risriditv or relaxation of the bladder and rectum mav 
act from spasmodic contraction, and the rate of respiration keeps pace 
with the fever and pulse. Alcohol users are prone to retention or sup- 
pression of urine (Anders.) 

Leucocytosis has been found. Complications that usually prove 
fatal are pneumonia, meningitis, uremia and paralysis of the heart and 
lungs. 

Heat-exhaustion usually has for prodromes dizziness, fainting, head- 
ache, nausea, thirst, drowsiness and yawning, lumbar aching or gastric 
pains, numbness and tingling of the extremities, and the general evidences 
of gastric atony and cerebral anemia. The patients cannot eat, but drink 
drink, drink, drink! The attack is characterized by a cold, clammy 
skin, great prostration with complete relaxation of the muscles, the 
pulse weak and fluttering or almost imperceptible, never wiry, sighing 
respiration, syncope, subnormal temperature at first, and all the symp- 
toms of a collapse that may prove rapidly fatal if not promptly compre- 
hended and remedied. Consciousness is not usually completely lost, 
and soon returns. Recovery from the first shock soon follows, but the 
weakness remains long. 

Persons who have suffered a true thermal stroke are sometimes 
peculiarly sensitive to heat thereafter and have to "follow the snow line." 
Various anesthetic and neurotic manifestations may follow, especially 
when the patient is exposed to heat, and these may indicate chronic 
meningitis. In all cases of this malady the patient requires watchful 
care for a prolonged period and he may never be able to again 
endure great heat, or even the direct rays of the sun, without suffering 
or danger. 



788 SUNSTROKE 

Diagnosis: — In true sunstroke we have hyperpyrexia and muscular 
rigidity, with unconsciousness as a rule; in heat exhaustion, alcoholic 
or opiate coma, there is a temperature not above and often below 
normal, muscular relaxation, and a pulse not the forcible one of sun- 
stroke. In apoplectic paralysis the rigidity is one-sided, the temperature 
normal, in meningitis and uremia the symptoms are too widely different 
to occasion difficulty. The coexistence of uremia should be considered. 

Prognosis: — In heat prostration this depends on the treatment. In 
true sunstroke we have to consider' the previous health and habits, the 
height of temperature and severity of the symptoms, especially those 
indicating the degree of damage inflicted on the nervous centers, and the 
complications. Very hot humid weather increases the tendency to death. 

Prophylaxis: — Persons whose bodily state renders them specially 
liable to heat-strokes must be warned of their danger and urged to keep 
out of the sunlight during the hours of its intensity, to avoid over-exertion 
and excitement, and the use of stimulating food and drink. Keep the 
bowels open and the head cool; see that kidneys and skin eliminate freely; 
dress to suit the weather rather than the fashion; eat just enough, and 
drink freely but not to excess, preferring cool but never iced drinks nor 
alcohol. Physicians and others can often do their work largely during 
the earliest morning and late evening hours, resting at home in the cool, 
well- ventilated and darkened cellar from n a. m. till 4 p. m. Employers 
might so arrange the working hours of their employees. Fat people must 
learn to let the ice-water cooler alone and drink moderately, after a suffi- 
cient meal of solids. Excessive thirst and sweating may be checked by 
a little phosphoric acid and agaricin in the water drank; acid enough 
to suit the taste, not sweetened, and a grain a day of agaricin.. To this 
may with benefit be added a grain of berberine. 

Treatment: — In cases of heat prostration lower the patient's head, 
loosen the clothing about the chest, and at once slip a granule of glonoin 
into his mouth telling him to chew it. Repeat this dose every five min- 
utes till his face flushes, meanwhile giving the same dose, gr. 1-250, of 
atropine to sustain the derivation of blood to the brain, repeating the 
atropine every half hour till the mouth dries.The heart needs help, but 
this is a case that may easily be over-stimulated. Give brucine gr. 1-67 
with each dose of atropine until the pulse approaches normal tone, and 
then less frequently. Perfect rest should be secured for the day, all friends 
excluded and if possible a trained nurse put in charge. The diet should 
consist of small portions — four ounces — of the most easily digested and 
nutritious foods, given every four hours, night and day. Soused pigsfeet, 
any other jellied meat, beef-powders or raw blood fluids, the predigested 



SUNSTROKE 789 

foods and the much-abused breakfast foods, are here useful. These 
may be alternated or accompanied by hot strong coffee and cups of fresh 
fruit juices. If there is marked heart-weakness massage and graduated 
exercises may be required before the patient is permitted to return to his 
occupation. We are well aware that the textbooks do not make so much 
of this malady, and pay scant attention to it; but a single case of fatal 
syncope, the patient rising to urinate an hour after his collapse, is enough 
to impress the physician with a sense of the danger of underestimating 
this condition. 

The hyperpyrexia cases require the instant, wholesale and unremitting 
application of cold, as quickly and as generally as the circumstances al- 
low. Affusions can be given wherever there is water, and even if the 
water is warm it abstracts some heat. Pack ice about the head and body, 
wrap in sheets wrung out of cold water and fan, throw ice water into 
rectum, in fact apply any form of cold that is most speedily obtainable 
and keep it up till the fever sinks to a safe limit — below 105 F. Bleeding 
may be necessary if cold can not be applied soon enough, the effects to 
be watched with the finger on the pulse, the patient sitting up, and neither 
too much nor too little blood taken to do the work. We may even be com- 
pelled to "bleed down to the brandy point", and then bring up, not with 
brandy but glonoin, and strychnine hypodermically. We can not endorse 
ihe advice to apply cold till the temperature falls to 102. Perilous collapse 
may follow pushing this application too far, and in one of the charts with 
which Anders illustrates this subject the temperature fell under ice baths 
from 107 to 95 F. Temperatures under 105 F. do not threaten speedy 
death from paralysis of the brain, but may be controlled by ordinary means; 
this is therefore our limit for the application of cold. If the temperature 
rises above 105 the cold should be re-applied. In the days when no dis- 
tinction was made between heat-exhaustion and true sunstroke, bleeding 
was applied to both conditions, with fatal results as to the former. It is 
rarely required when efficient applications of cold can be made, but when 
none of these is available venesection becomes our principal means of re- 
lieving the brain from a strain the delicate cerebral tissues are not cal- 
culated to long withstand. The abstraction of blood from a full-blooded, 
beefy man is a trifle anyhow, and now that the superstitious dread of 
depletion has subsided we may hope to see this potent weapon restored 
to the hands of the profession. 

The use of sedatives such as aconitine and veratrine comes later, in 
the period of febrile reaction, when they spare us the difficulty that may 
attend the applications of cold in places unsuited for such care. Either 
should be given in the usual manner, very small doses very frequently 



79o SUNSTROKE 

repeated until the desired effects are manifest. Precautions should be 
taken to keep the patient quiet, his head cool and him well shaded, as 
long as the temperature is above normal. The diet should be light and 
unstimulating, barley or rice water, cold consomme, water ices, iced coffee 
in very small doses, eggwhite water, buttermilk, junket, fresh fruit juices, 
in four-ounce doses every four hours, with bits of ice to be sucked when 
thirsty. The bowels must be thoroughly emptied by full doses of calomel 
and jalapin, a grain each, repeated, or by the speedier cathartics like 
elaterin if the need is pressing. After this the salines with an evening 
dose of calomel or podophyllotoxin, and an occasional colonic flush, will 
do well. The renal elimination must be sustained from the start, and 
half-pint colonic enemas of saline solution may be early advisable, as 
suggested by Packard. Bryonin is a good selection here, or apocynin 
if the heart is weak. Of the former gr. 1-67 every two hours, of the latter 
gr. 1-12 at like intervals, will usually accomplish the purpose. 

If free perspiration does not ensue after reaction sets in it should be 
aided by pilocarpine hypodermically, gr. 1-6, repeated if needful. Hypo- 
dermics of morphine have been highly recommended for controlling con- 
vulsions, but if this be a form of acute toxemia veratrine would be pref- 
erable. 

When the storm has passed the cerebral tissues may be encumbered 
with debris, and a prolonged course of absorbent remedies may be ad- 
visable. Sluggishness of the liver may demand an evening dose of a grain 
of emetine occasionally. Whatever remedies may be indicated they 
will be required for a prolonged period if we expect to rid our patient 
of the difficulties remaining after such an attack. However, either form 
of the malady may enable us to exercise a degree of control over a recal- 
citrant patient impossible previously. 



PART XI 

ANIMAL PARASITES 



PSOROSPERMOSIS 

The lowest forms of protozoa are known as psorosperms, sporozoa, 
and from their relation to cells as cytozoa. The amoeba coli of dysentery 
belongs among them, and such blood parasites as the malarial plasmodium 
are closely related. Several coccidia are found to produce this disease 
in man. The coccidium oviforme causes liver disease, with tenderness, 
chilliness, fever, malaise and stupor progressing to coma. The tumors 
may be felt projecting from the surface of the gland. In a case reported 
by Osier death occurred on the 14th day. 

In an intestinal form nausea, vomiting, diarrhea and the typhoid 
state may be presented, the kidneys being affected as shown by hematuria 
and irritability of the bladder. In the skin the parasites cause follicular 
'keratosis, with Hard, crusty papules, becoming confluent; on the face, 
lumboabdominal and inguinal regions. In carcinoma, epithelioma 
and Paget's nipple disease coccidia are to be found in and between the 
abnormal epithelial cells. Their significance is as yet uncertain. 

Prophylaxis consists in cleanliness as to the preparation of vege- 
tables eaten raw, which may be contaminated by the excreta of infected 
animals. The treatment is as yet strictly symptomatic, the only specific 
observation being the destructive action of quinine solutions on the dys- 
enteric amoeba. Would the blood-vessels carry this drug to the parasite 
if it were given to saturation? 

DISTOMIASIS 

The liver fluke, distoma hepaticum, may be transferred to man from 
the horse, goat, ass, sheep or rabbit. It is over an inch long, and lives 
in the biliary passages, being discharged with the feces. The ciliated 
embryo escapes from the egg, is swallowed by a member of the snail 
family, in which it undergoes development into a sporocyst, which gives 
origin to radiae or parent nurses. These give birth to daughter radiae or 
cercariae, which leave the snail and attach themselves to aquatic plants, 



792 DISTOMIASIS. 

where they await the time when they and the plant will be swallowed by 
some animal, and in due time return to torment the higher animal from 
which their remote progenitors set forth on their wanderings. Why so 
much trouble should be taken to prepare a means of injuring the health 
of man or animal we leave to those whe fully believe that nothing is created 
in vain. 

When the trematodes collect in sufficient numbers in the biliary pas- 
sages the liver enlarges, jaundice and ascites ensuing. Pain is often 
present, and heart murmurs often ' coexist. Hepatic atrophy follows in 
time. Sometimes they cause a peculiar barrel-shaped bulging, with the 
abdominal walls over the liver tense. In a Japanese epidemic there were 
noted emaciation, diarrhea, hepatic enlargement and ascites. 

The prognosis is fatal, the treatment not yet devised. 

Possibly salicylic acid, which is taken up by the liver, might render 
the biliary passages unpleasant to the intruders, or the odor of the sul- 
phides pushed to saturation might induce in them a desire to move out. 
Failure of the old methods does not signify that no remedy exists but 
simply that no one has as yet hit upon the right one. 

Other members of this interesting group are the distoma lanceolatum 
of cattle; crassum, a larger variety; sibiricum, pulmonale, spatulatum 
endemicum, amphistomum hominis, hematobium. The pulmonale or 
lung fluke has been found in the tiger, hog, dog and cat. It prevails in 
man in Japan and China. It is 8 to 1 6 mm. long, 4 to 6 broad, 2 to 5 
thick. The flukes with eggs are found encysted together in the lungs of 
affected individuals. These are swallowed by man, encysted or as free 
embryos in the drinking water. It has been found in hogs in the United 
States, and may be quite frequent but mistaken for tuberculosis. 

The majority of cases recognized are among farmers. The ages va- 
ried from eleven to thirty years in Stiles' cases. Cough is usual, with 
rusty sputa. Jacksonian epilepsy has followed their migration to the 
brain. The diagnosis is made by finding the eggs in the sputum, large 
dark-brown, thick shelled, operculated ova. The prognosis depends on 
the number of the parasites and the age of the patient, the young 
and old bearing the disease badly. The treatment is strictly 
prophylactic. 

The blood fluke, Bilhartzia hematobia, is a narrow worm with an- 
terior abdominal sucking disks. It prevails throughout Africa and pene- 
trates the skin of bathers in the rivers. It may also enter with the drink- 
ing water. The parasites are found in the bladder, the pelvis of the kid- 
ney and the veins, especially the portal. It causes hematuria and dys- 
uria. The ova may be detected in the urine. Prophylaxis seems to 



ASCARIASIS 793 

look with suspicion in Africa on the use of raw water for drinking and 
bathing. The extract of male fern has been recommended internally. 

ASCARIASIS 

The ascaris lumbricoides or round worm is the most common of the 
intestinal parasites of man. It may appear in the second year. It in- 
habits the duodenum and jejunum and may be present in large numbers. 
The writer has known seventy-five to be discharged at one time by a child. 
It resembles an earth worm in shape, but the male measures four to eight 
inches in length, the female nearly double this. The head has three toothed 
papillae, the tail is straight in the female and curved in the male. The 
worms develop from eggs .05 to .06 mm. long, elliptic, dark red, w T ith a 
thick tough envelope. They enter the human stomach through food 
and drink. This worm sometimes migrates into the stomach whence 
it is vomited, or into pharynx, mouth, nares, larynx, trachea, Eustachian 
tube and bile ducts, where it may cause serious trouble or even death. 

The worms may be present even in numbers and give rise to no rec- 
ognizable symptoms. In the case above referred to the mother acknowl- 
edged that she "had not noticed anything whatever ailing the child". 
When the worms migrate, however, serious symptoms may result. In 
some cases the presence of the worms in the intestine is attended by colicky 
pains, nausea or vomiting, indigestion, diarrhea, restlessness, very often 
irritability of temper, loss of appetite, itching at the nose or anus, dis- 
turbed sleep with grinding of the teeth, salivation and nervous twitch- 
ings. In children with weak nervous equilibrium these worms may cause 
convulsions, chorea, dilatation of the pupils, headaches, mental disorders 
or contractures. 

Complications: — Obstruction of the bile ducts will cause jaundice. 
The intestines may be obstructed by masses of worms. Entering the 
air-passages during the night, suffocation may follow. Abscesses have 
pointed externally and discharged these worms. 

The diagnosis can be made by finding the worms or their ova in the 
stools. The prognosis is good if the worms remain in their proper 
place. 

Worms may be prevented by the use of absolutely pure drinking 
water. In order to obtain a good effect from anthelmintics the patient's 
bowels should be cleared by a laxative and very little food given for 
thirty-six hours; then calomel and santonin may be given, 1-10 grain 
of calomel and 1-2 grain of santonin to a child four years old, repeated 
every hour until the urine shows a distinct tinge of yellowish green. 



794 OXYURIS VERMICULARIS 

The vision is generally similarly altered, everything appearing to the 
patient to have a chlorine-green tint. Spasms are said to occur some- 
times but the writer has never known this to happen when santonin and 
calomel have been given together. Another laxative should follow. 
The treatment may be repeated twice a week until no more eggs can be 
detected in the stools. Most physicians are satisfied when a few worms 
are brought away. Investigations made at the Children's Hospital 
in London some years ago showed that not one of the ordinary anthel- 
mintics would completely clear the alimentary tract so that no more 
eggs appeared in the stools. The only remedy that succeeded in ac- 
complishing this was cowhage down. To prepare this the pods are 
dipped into syrup and scraped off until the syrup is thick with the down. 
This is then administered in teaspoonful doses. It does no apparent 
harm to the patient, but the worms are passed penetrated in every 
direction by thousands of the prickles. Chelonin has been recently 
suggested as an effective remedy for these and other intestinal para- 
sites. Many reports have been received by the writer testifying to the 
efficacy of this remedy. It is usually administered in the formula sug- 
gested by Dr. Barron, each granule containing chelonin gr. 1-6, san- 
tonin gr. i-iq and podophyllin, gr. 1-33. Of these a child from six to 
ten years of age should take three at bedtime and one every two hours 
next day until effect. 

OXYURIS VERMICULARIS 

The seat, pin or thread-worm inhabits the rectum, ascending to the 
colon. It is a small white worm, the female about half an inch long, 
the male one-sixth inch. They may be present in enormous numbers. 
When the ova have been swallowed the eggs develop in two weeks. 
The latter are oval, 1-500 inch in length, and difficult to kill. These 
Worms are discharged with the feces and often crawl out voluntarily, 
sometimes entering the vagina where they cause intense itching. The 
eggs are usually taken into the stomach with vegetables and fruits that 
are eaten raw. Scratching sometimes infects the finger nails which 
carry the eggs to other parts. These worms cause intense itching about 
the anus, with rectal burning and tenesmus, inducing restlessness and 
disturbing sleep. The itching is worse at night. Any eruption about 
the anus with itching should lead to an examination for the worm. 
Many nervous symptoms may result and bad habits have been induced 
by the irritation. 

The diagnosis is made by the rectal irritation, and the detection of 
the worms in the feces, or of their eggs. The prognosis is good. 



UNCINARIASIS 795 

TreBtment: — The remedies recommended for round worms may be 
usefully given to destroy thread-worms anywhere above the rectum. 
In this we may reach them better by enemas. The rectum should be 
washed clean of feces and then a pint of decoction of quassia should be 
thrown in. Other remedies found useful by enema are phenol, turpen- 
tine, tannin, vinegar, camphor, calcium sulphide and oil of eucalyptus. 
The injection should be repeated twice a day for two weeks. Obsti- 
nate recurrences show that worms are breeding in the cecum, and in 
this case anthelmintics must be given by the stomach. The eggs may 
be deposited in the folds around the anus; for this reason, as well as to 
relieve the itching, mercurial ointments may be applied. 

Ascarus Alata or Mystax infests the intestines of the dog and cat, 
and a few cases have been found in man. The treatment should be 
the same as that for the round worm. 

Trichocephalus Dispar is a worm two inches long, the anterior two- 
thirds of its body being hair-like, the posterior portion thick, straight 
and blunt in the female, rolled in a spiral in the male. It inhabits the 
cecum, sometimes the colon also, and is found in great numbers. It 
is more common in Europe than in America. Infection is caused by 
swallowing the eggs, which are about 1-500 inch in length. No special 
symptoms have been attributed to its presence. Diagnosis is made by 
recognizing the eggs in the feces. No especial harm seems to be caused 
by the worm, but if the host does not care to harbor the squatters they 
may be driven out by a few doses of cowhage down or male fern. 

- UNCINARIASIS 

The ankylostomum or uncinaria duodenale is a nematode worm, 
the female half an inch long, the male somewhat shorter. The body 
is thread-like, the head conical, the mouth large, bell-shaped, surrounded 
by a horny capsule with four hooked teeth below and two above. This 
worm inhabits the small intestine. The eggs develop in mud, the larvae 
remaining dormant until taken into the human stomach with water, 
food or the dirt on the hands. They develop in the bowel into the 
mature worms, but do not breed there. 

In many cases these worms enter through the feet, causing what is 
known as ground-itch, and thence penetrating to the intestines. The 
disease caused by them prevails over all the Gulf and South Atlantic 
states, as far north as Southern Illinois, and in Puerto Rico. The hook- 
worm abstracts its nutrition from the plasma of blood in the intestinal 
vessels. It is found in the mucous or submucous coat coiled up in a 



796 TRICHINIASIS 

little blood cavity. Chronic catarrhal enteritis attends and the heart 
is frequently enlarged. 

The chief symptom is a progressive anemia, the skin being yellowish 
or dirty gray, the rapidity of the symptoms depending upon the number 
of the parasites. The anemia sometimes resembles the pernicious form. 
The red cells and hemoglobin may be largely reduced, the cells being 
pale and irregular, with many normoblasts. Loss of appetite, colic, 
nausea and vomiting, constipation and diarrhea, are often present. In 
acute Cases there may be marked' debility, dyspnea and dropsy. The 
weight is sustained. Edema of the ankles, insomnia, headache, faint- 
ness, palpitation and scanty perspiration are common. The kidneys 
are unaffected. There may be slight fever, and ulcer of the cornea has 
been reported. One of the most interesting features of this disease is 
its effect upon the mental functions. The patient is sluggish and dull, 
exerting himself no more than is absolutely necessary. An investigator 
in the South called at various schools and asked for the especially dull 
scholars. In every instance he found that these were affected with 
hook-worms. 

Hookworms cause the chlorosis of Egypt, tunnel or mountain anemia 
of Italy, brickmakers' anemia in Belgium, and the cachexia of coal- 
miners, as well as the peculiarities of the Southern clay-eating cracker. 

Diagnosis: — This lies in detecting the eggs or worms in the stools. 
The eggs are oval, 1-500 inch in length, the shell much thinner than is 
that of the round worm. The disease continues for years. If not 
treated, death may result from the progressive anemia, diarrhea and 
nutritive disorder. 

Treatment: — In infected districts the water should not be drank until 
it has been boiled, and people must be warned against going bare- 
footed. Thymol is the best remedy as yet known, but must be given 
in doses that would ordinarily be considered perilous. 

Thirty grains should be given every two hours for four doses, on an 
empty stomach, and followed in eight hours by a full dose of castor oil. 
The treatment should be repeated every week until no more worms or 
their eggs appear. 

TRICHINIASIS 

The trichina spiralis is a worm, the male about 1-20 inch long, the 
female more than double this length. The head is pointed and slender, 
the tail blunt. It is found in the intestines of the rat, dog, cat, hog, and 
man. The embryo is about 1-25 inch long and is found coiled up in a 



TRICHINIASIS 707 

capsule in the sarcolemma . When the muscular tissues containing 
these embryos are eaten by animals the larvae are liberated by the diges- 
tion of the capsules, and after two to four days' residence in the intes- 
tine become sexually mature, and within a week mure produce many 
young. The parents survive about a month, the female bringing forth 
many broods. The embryos at once penetrate the walls of the intestine 
and pass along the connective tissue planes to their destinations in the 
muscles, which they reach in seven to ten days from the time the trich- 
inatous meat was eaten. Here their presence causes local inflammation 
and irritation, during the two weeks occupied in their further develop- 
ment. In four to six weeks the fibrous capsule is formed, and in this 
the worms may exist in a dormant state for years. The capsules in time 
become calcareous. 

The diaphragm is most thickly studded with the embryos, then the 
intercostals, abdominal muscles, neck, larynx, head, eyes and extrem- 
ities. They are present in the bowels up to the seventh week. In the 
muscles they cause inflammatory disturbance with the usual results. 
The trichinae are visible to the naked eye as little whitish specks, oat- 
shaped, along the muscular fibers. 

Trichinae are derived by man from infected pork. It was once 
thought that the pig obtained the parasites from the rat, but investiga- 
tions has made it evident that only the rat about packing-houses is thus 
infected from consuming infected offal, while the country rat is sound. 
About two per cent of hogs slaughtered and inspected in the United 
States are trichinatous (Salmon), and Osier says that from 1-2 to 2 per 
cent of all (human) bodies examined post mortem contain trichinae. 
This would indicate that trichiniasis is much more frequent than is sus- 
pected. The infection comes from eating raw or insufficiently cooked 
pork, since thorough cooking destroys the life of the parasites. 

Symptoms: — Within two days after eating infected pork the eater 
presents symptoms of acute gastrointestinal disorder, nausea, vomiting, 
diarrhea and colic, the attack sometimes being choleraic in violence. 
A sense of debility comes on before the embryos have begun to pene- 
trate the muscles, which may be due to a toxin secreted by the trichinae. 
There may be soreness in the abdomen as the intestines are irritated 
by the ingress of countless parasites From the tenth to the fifteenth 
day migration commences and a chill ensues, followed by fever ranging 
from 101 to 104 F., and evidences of inflammation of the muscles. Tht>e 
become tender, painful, swollen and edematous, sometimes contracted 
and always painful on motion. The functions of mastication, deglutition 
or phonation, etc., may be hampered as the muscles concerned are 



798 TRICHINIASIS 

invaded. As the diaphragm is most infested, dyspnea is an early and 
prominent symptom. The pulse and fever show non-periodic variations, 
and the temperature may be subnormal. Edema appears about the 
seventh day, about the eyes, and extends widely. It remains some 
days then subsides and may return. Ascites has occurred. Edema 
of the larynx or bronchopneumonia may cause serious trouble. Free 
sweating may occur and continue for weeks. Boils, nettle-rash, pruritus 
and other cutaneous manifestations may occur. Various nervous symp- 
toms may be present, such as headache, insomnia, restlessness, delirium, 
dilatation of the pupils, suspension of tendon reflexes, and the blood 
becomes impoverished, the patient losing weight and strength rapidly. 
There is an increase of the eosinophiles, up to 37 per cent (Brown). 
Albuminuria occurs sometimes, and the condition may simulate that 
present in typhoid fever. Pulmonary complications are most frequent. 
The course varies with the number of invaders and the muscles they 
attack, from two weeks to two months or more. Usually the embryos 
become encysted within six weeks. 

Diagnosis: — Gastrointestinal irritation, followed by sudden swelling 
about the eyes, after muscular soreness, with fever and later profuse 
sweats, tender hardness of the muscles, tendency to flexures or at least 
pain on moving some muscles especially those known to be most affected 
in this malady, the marked -dyspnea, and general edema following that 
of the face, hoarseness and rapidity of respiration without apparent 
cause, are significant. The diagnosis is rendered positive by examining 
a fragment of affected muscle; or recognition of trichinae in the pork, 
or in the intestinal mucus. In ptomain poisoning we have a rapid 
development and course, dryness of the throat and skin, jaundice, 
ocular disturbance and no edema or muscle implications. Rheumatism, 
cholera, typhoid fever, and acute polymyositis are mistaken for trich- 
iniasis by careless observers only. 

The prognosis depends largely on the number of invaders and the 
acuteness of the attack. Early diarrhea is favorable as thereby many 
trichinae are swept out of the bowels. Packard found the mortality 
about 24 per cent. Death may be delayed till the sixth week. 

Treatment: — Discourage the eating of raw pork. Packers should 
destroy the offal of trichinatous hogs and carefully prevent the access 
of rats which might thus become infected and in turn pass the disease, 
to other hogs. Inspection should be totally independent of the packers, 
interests. 

As an early diarrhea improves the diagnosis, the indication is to 
empty the stomach and bowels as quickly as possible after partaking 



FILARIASIS 799 

of the infected meat, which may be done 1))' an emetic of mustard water 
and an ounce of castor oil to which a drop of croton oil may 
be added in dealing with healthy adults. Follow this with glycerin, 
absolutely free of w r ater, a tablespoonful every hour. Why? 

Dornblueth, experimenting with trichinae embryos, found that glyc- 
erin applied to them on microscope slides acted as sulphuric acid does 
on animal tissues, abstracting water so energetically that the tissues 
were charred. Acting on the suggestion he treated some cases with 
glycerin in the doses mentioned, and found it harmless to the patient, 
while the disease did not develop. But as the glycerin acts by absorbing 
water from the embryos it is obvious that unless it comes in contact with 
them while still greedy for water, it is useless. Dornblueth advised that 
the glycerin be also given in elastic keratin capsules which might carry 
the remdey undiluted into the intestines, and if keratin would do this it 
would be a wise method. Meanwhile as we have no such capsules we 
must rely on the ordinary administration. It is obvious that the advice 
to "try glycerin," without this explanation, is of slight value. 

It seems obvious that here is a field for intestinal antiseptics, when 
the case is recognized while the parasites are yet in the alimentary canal. 
Of these agents the oil of male fern would seem best, as its destructive 
pow r er over other parasites is well proven. Give full doses as for tape 
worms, or administer an ounce of oil of turpentine. The parasites that 
have penetrated beyond the bowel are not supposed to be within our 
reach. Picric acid has been suggested, and it should be tried. The 
treatment here is symptomatic. — the defervescent alkaloids for fever 
and inflammation, heart-tonics to sustain the vital forces, cicutine for 
muscular distress, anodyne lin ments with gentle massage and faradism, 
and a liberal but non-stimulating diet. Possibly the x-ray or static 
electricity may prove destructive to these parasites; they may prove 
amenable to the influence of the sulphides, echinacea, bebeerine, ber- 
berine, quinine; some agent that goes to the muscles or the connective 
tissue may prove too much for the intruders. By trying every possibil- 
ity we are more apt to find out things than by sitting down and waiting 
till they come to us. 

FILARIASIS 

Several varieties of filarial are found in man, the principal being the 
filaria sanguinis hominis nocturna and f. s. h. diurna. The first is a 
white opaline thread-worm, the male over 3 inches long, the female 
twice as long. The second is known only in embryos, which show gran- 



800 FILARIASIS 

ulations. It prevails throughout the tropics up to Spain in Europe and 
Charleston in the United States. A large proportion of the people may 
be affected — in Samoa one-half. The embryo of nocturna is about 1-80 
inch long and as thick as a red blood corpuscle. The skin or sheath 
is loose and too big for the worm. The parasite is rarely to be detected 
in the blood by day but becomes abundant as night comes on, the con- 
trary being the case with diurna. In patients who sleep by day the 
worm is found during sleep; but the appearance of the parasites in in- 
creasing numbers commences hours before the sleep begins. During 
the time of their disappearance from the peripheral vessels they collect 
in the arteries and the lungs. 

Filaria embryos are taken up with the blood by the mosquito, in 
whose body they undergo development, first casting off the sheath, and 
in from six to twenty days or more are ready to enter the blood of the next 
victim tapped by the mosquito. Whether the parasite can also enter 
man by drinking water or any other route than by the bite of the mos- 
quito is uncertain. The Culex is probably the insect involved. The 
filaria come to sexual maturity in the lymphatics, whence the new brood 
pass to the blood. 

Symptoms: — Like the round worm the filaria may cause no disturb- 
ance unless the parents by their size and number block lymphatics or 
blood-vessels. They may plug the thoracic duct, or iriduce inflammation, 
with lymphatic engorgement or edema. The lymphatic varix may be 
extensive, with collateral circulation established. The contents of the 
dilated vessels are chylous. The dilated abdominal mass may be a foot 
in diameter. The scrotum may be similarly enlarged, or the glands in 
the groin; the genitourinary lymphatics may open into the urinary chan- 
nels and chyluria result, or we may have chylocele or chylous ascites. 
Other lymphatic glands or tracts are less frequently affected. In such 
localizations the filarial may in time disappear from the blood. 

In elephantiasis Arabum it is unusual to find filarise in the blood. 
This malady is regarded by Manson as due to filariae, though they can 
not as a rule be found in the blood. He attributes the lymph stasis to 
the presence of filarian ova by which the channels are blocked. These 
may be prematurely extruded by mechanical causes operating on the 
parasites in the lymphatics of the limbs, and the ova being larger than 
the lumen of the vessels cause obstruction. This, however, gives rise 
to edema, but inflammation is necessary to develop true elephantiasis, 
and this may be readily excited in such a tract by the slightest injury. 
Hence frequent attacks of erthyema are characteristic of this malady. 
Hyperplasia of various tissues ensues. 



FILARIASIS 80 1 

The death of a filaria may be followed by its absorption, or it may 
induce suppuration and abscess. Lymphangitis is common in all forms 
of filarial disease, and has been termed elephantoid fever. The lym- 
phatic vessels and glands swell, a red streak is visible, with headache, 
anorexia, disturbance of the stomach and rarely delirium. Following the 
initial chill the fever may rise high and the skin become tense and hot. 
The attack ends in a discharge of lymph or in profuse sweats. There 
may be a close similarity to malarial fevers. The part should be ele- 
vated, cooling lotions applied, the bowels cleared, and the fever com- 
bated by the defervescent alkaloids applied as per indication. Mercurial 
ointments applied over the inflamed vessels moderate the inflammation 
and hasten resolution. The greatest comfort results from the appli- 
cation of a rubber bandage to the affected limb during the intervals, 
continuously, the erythematous attacks becoming less frequent and the 
enlargement subsiding. 

Varicose inguinal glands, enlarged scrotum, chyluria and chylocele 
are variously combined. They come on without acute symptoms and 
are unattended with suffering. Lymph can be withdrawn by aspirating, 
which coagulates rapidly and may contain living embryos. This tumor 
should not be mistaken for hernia. Any chronic swelling in this region, 
in the tropics, should be regarded as possibly filarial (Manson). They 
are best let alone; and usually form an essential collateral circulation. 
Other lymphatic groups are less frequently affected. When the scrotum 
is affected erythema is common, abscess rare. Treatment consists in 
elevating the mass, applying elastic compression, and in case of 
necessity removal by amputation. Manson urges that the entire mass 
be removed, the gap being closed by traction on the integument of 
the thighs. 

Chyluria results from rupture of a filarial varix into the bladder. 
Aching in the back, groins and pelvis may precede the appearance of the 
milky urine, or obstruction of the urethra may be the first indication. 
The urine may be pink or red. It coagulates, and usually contains em- 
bryos. Chyluria may be continuous or intermittent. It causes anemia, 
debility, depression and incapacity for severe exertion. It is especially 
liable to appear during pregnancy or lactation, or after muscular strain. 
Manson denies that any treatment influences the malady beyond rest 
and similar general measures that may be indicated. Lawrie advised 
thymol and others methylene blue, but it is a question whether any 
means should be employed to kill the parasites which are far more dan- 
gerous dead than alive. Orchitis and synovitis occasionally result from 
filarial invasions. 



802 GUINEA WORM: FILARIA MEDINENSIS. 

Elephantiasis may affect not only the scrotum and legs but the vulva, 
arms, breasts, or limited areas of the skin. 

Prophylaxis in countries infested with filarial consists in protection 
against mosquitoes, and the use of pure water. Patients should likewise 
be screened to prevent infection of mosquitoes. 

GUINEA WORM: FILARIA MEDINENSIS 

Guinea worms are found in India, the west coast of Africa, and in 
one part of Brazil. Occasionally they are seen in sailors entering our 
hospitals. They attack the horse, dog and ox. The male has not been 
recognized. The female measures one to three feet in length, or more, 
and is i-io inch thick; milkwhite, smooth, the tail hooked, the head end- 
ing in the cephalic shield, with six papillae. The body is almost com- 
pletely occupied with the uterus gorged with embryos. This worm 
inhabits the connective tissues, and showing herself beneath the skin 
anywhere, disappears and may show up lower down, finally approaching 
the surface about the ankles. A small blister rises here, breaks and the 
head of the worm protrudes with an inch of the body. If this is broken 
off the worm disintegrates and the result is septic suppuration along its 
course. The head is carefully drawn out as far as it is loose and wound 
on a match stick, and supported by a bandage. Each day a few inches 
more can be thus withdrawn, until in a week or more the entire worm 
has been wound on the stick and extracted. 

The worm enters the human stomach with water drinking. The 
custom now is when the worm appears to encourage her to discharge 
her young by applying water to the surface of the blister, when the em- 
bryos will be extruded. This will continue for two weeks, when the 
parent worm will emerge. 

No efforts at traction must be made while the embryos are being 
emitted. Emily shortens the period by injecting into the worm a solu- 
tion of mercury bichloride, i to iooo, which kills the parasite, after 
which extraction is easily accomplished. The embryos enter the body 
of a marine animal, the cyclops, and there undergo a stage of develop- 
ment before they are ready to attack their next host. 

Prophylaxis requires the use of only pure water as a beverage in 
infected districts. Possibly the tendency to the use of alcoholic quali- 
fication has more to justify it than the prohibitionist would care to admit. 

Other filariae that attack man, generally in Africa, are the f. immitus, 
labialis, lentis, trachealis, bronchialis, loa, and hominis oris. 

The eustrongylus gigas is a huge worm infesting animals, fish being 
the intermediary host, rarely causing hematuria in man. Anguillula 



ECfflNOCOCCUS 803 

stercoralis is found in the stools of some tropical dysenteries, along the 
Mexican Gulf. Echinorhynchus moniliformis is found in rats and has 
been detected in man, in Sicily. 

SLEEPING SICKNESS: TRYPANOSOMIASIS 

Trypanosoma is a flagellated hematozoon, transmitted by a fly, found 
in other parts of the world but not in America. The malady begins 
with erythema and edema, cachexia developing with wasting, debility 
and feebleness of the legs. Irregular fever rises to 104 with correspond- 
ing pulse rate, restlessness, delirium, difficulty of speech, Cheyne-Stokes 
respiration and coma. The spleen may be enlarged and tender. Anemia 
follows. The lymphatic glands contain many of the parasites. The 
coma which gives the disease its common name develops late. 

Several observers report favorably on the use of arsenic in sleeping 
sickness. E. J. Moore found hypodermics of an ounce of 1 per cent 
sodium arsenate solution proved useful in cattle infected, while Ehrlich 
and Shiga found that trypan red induced a reaction in the body fatal to 
the parasites though it had no direct influence. Laveran found that 
arsenous acid, 1 to 20,000 of the animal's weight, cleared the parasites 
from the blood of infected rats. Koch confirms the value of arsenic. 

ECHINOCOCCUS 

This tapeworm especially infests the dog. It is about J inch long, 
and consistss of three or four sections. The intermediary hosts are the 
hog, ox, horse and sheep, rarely man. Dogs ingest the larvae and in 
two months the mature forms are developed, eggs, larvae or adults being 
voided. 

The six-hooked embryos penetrate the intestinal walls or the portal 
vein and pass into the viscera or muscles where they develop into larvae 
and form hydatid cysts. The irritation they cause induces the forma- 
tion of a fibrous envelope about them. The cyst consists of two walls 
containing a clear fluid and from the inner wall project numerous second- 
ary cysts containing heads of larvae. In these a third generation may 
develop. In these are found the heads of future teniae, with four sucking 
disks and a circle of hooklets. Each scolex that reaches the stomach 
of the dog becomes an echinococcus The fluid has a specific gravity 
of 1005 to 1012, and consists of 98 per cent water, sodium chloride, car- 
bonate and sulphate, cholesterin, uric acid and traces of dextrose. When 
the parasite dies the cyst contents become thick, puttylike, granular, 



8o 4 ECHINOCOCCUS 

or calcify. The cyst may discharge its contents into surrounding tissues 
or cavities, causing suppuration or new cystic formations, or being dis- 
charged through the natural emunctories. 

Hydatids come usually from careless handling of dogs, and allowing 
them to inhabit the kitchen. Women and young children are most 
affected. Where men and dogs live together as in Iceland, the disease 
is most prevalent. The liver is most frequently affected, then the lungs, 
bowels, urinary apparatus, brain and cord. 

Symptoms: — In the liver the development may not be noted by 
symptoms unless a hepatic duct is occluded, when jaundice will follow. 
Progressive decline in strength and loss of flesh, sense of weight and 
dragging, and the appearance of a fluctuating hepatic tumor, rarely pain, 
indicate the development of the parasite in the liver, Pushing up the 
diaphragm it may cause dyspnea and cough. Compressing the portal 
vein the spleen swells, the intestines are congested, hemorrhoids develop, 
followed by ascites, etc. The sac may discharge into the air-passages, 
the intestine, or the pleural or peritoneal sacs. Suppuration is indicated 
by chills followed by fever of septic type. Unless evacuated externally, 
rupture causes collapse. 

If presenting anteriorly the tumor may display visible bulging. Pal- 
pation reveals a fluctuating mass, light percussion on the opposite side 
giving the hydatid thrill. The liver elsewhere is uniformly enlarged, 
the spleen passively congested; percussion is dull over the mass, the 
stomach displaced, and a short, sharp, booming sound has been described 
on percussing the tumor (Santoni). 

Diagnosis: — At first this is inferential, until the mass can be isolated 
by physical examination. Anders gives the following: 

Hydatid cyst: Swollen gallbladder: 

history negative except for dog fancy. gallstone history. 

no pain or jaundice. biliary colics and jaundice. 

growth depends on location. location uniform. 

hydatid thrill perhaps. never present. 

not very movable. more movable. 

Hydronephrosis : 

history negative. renal stone or vesic inflammation, 

urinalysis negative. shows renal disease, 

hepatic tumor. iliac tumor, does not move with liver 

duration varies, uremia rare. brief; often ends in uremia. 

Pleural effusion: 

slow onset, no pain or fever. sudden, pain, fever, dyspnea, 

changed position does not alter signs. percussion alters with position, 

aspiration reveals hydatid elements. albumin, lymph, high s. g. 

chronic course. usually acute. 

In the lung hydatids most frequently attack the right lower lobe, 

sometimes the pleura; causing pain, fever, cough, dyspnea, bulging, 

effusion, hemoptysis, sputa containing hydatid elements, dullness over 



TAPEWORM 805 

the tumor. Occasional results are empyema, perforation of the chest 
wall, dislocation of the heart, and pulmonary gangrene from compres- 
sion. The location, curved upper edge of dull area, unchanged by change 
of posture, and absence of wasting, distinguish from phthisis and pleurisy. 

Echinococci have been found in the mediastinum, heart, brain, cord, 
meninges, spleen, kidneys, peritoneum, bladder, prostate, testicle, ovary 
uterus, omentum, mesentery, pancreas, arteries, lymphatics, thyroid, 
muscles, bones, joints, parotid gland, orbit and mamma. This list 
might be enlarged. 

Urticaria sometimes follows puncture of a hydatid cyst, and is then 
diagnostic. The prognosis is grave, but cases may exist for many years. 
Calcification sometimes occurs. Rupture and suppuration are to be 
dreaded. 

Prophylaxis includes the feeding of dogs with cooked meat, and lim- 
itation of association with them. Treatment is direct and mechanical, 
including excision, electrolysis, and the injections of the cysts when 
accessible with iodine, bile, etc. Otherwise the drug treatment is strictly 
symptomatic. The static spark, x-ray and similar applications are yet 
to be tried. 

TAPEWORM 

The tapeworms are taken into the human alimentary canal with the 
flesh of infected animals as embryos, develop there, and their ova pass 
out to be developed elsewhere. In the host animal they penetrate to 
the muscles where they form small cysts, containing a head, the scolex 
or nurse. These cysticerci are known as measles. If the animal lives 
several years the cysts die and are calcified. If eaten as food the cyst 
develops into a tapeworm. Three months later the matured segments 
of the worm commence to pass out of the bowel, some with the stools, 
and a few by their own system of locomotion crawling out of the anus. 
Each segment constitutes a single hermaphrodite animal, the uterus 
filling most of the body. It is supposed that the various segments are 
fertilized by others as the worm shifts its position in the bowel. 

Tenia solium is the most common form found in Europe. It inhabits 
"measly" pork, and is destroyed by thorough cooking. The worm 
develops to a length of six to twelve feet, the head round and the size of 
a small pinhead, armed with four suckers and 26 hooklets. The neck 
is like a bit of thread, growing thicker and the segmentation more evi- 
dent as it leaves the head, flat and wider until the lower third is reached, 
when a segment becomes narrower and longer, the mature ones being 



806 TAPEWORM 

about 1-2 inch long, and 1-4 inch broad. The uterus is crowded 
with eggs, each containing an embryo with six hooklets. 

Tenia mediocanellata or saginata is obtained from beef. This is 
the most common in the United States. The head has disks but no 
hooks, the worm grows to a length of 20 feet, and the segments are larger 
in all dimensions. The matrix is differently arranged in each variety 
of tenia and constitutes one of the means of differentiating them. The 
proglottides of this one are especially apt to crawl out at the anus. 

Tenia lata, bothriocephalus latus, the fish tapeworm, is common in 
northern Europe and Switzerland. It reaches a length of 30 feet. The 
head has no hooks but two lateral sucker grooves. The segments are 
short and broad, the matrix arranged as a rosette, the ova larger, thin- 
shelled, with a lid. They develop only in fresh water. Cats are in- 
fested with tapeworms and the ova they leave around the house are 
lidded. The lata embryos develop in the tissues of fish and when these 
are eaten, insufficiently cooked, pass alive into the intestines of the eater. 

Symptoms: — The existence of tapeworms is usually unsuspected 
until the proglottides commence to pass in the stools. In nervous per- 
sons almost any neurotic manifestations may follow the knowledge of 
such infection. In some persons the worm is accompanied by anorexia 
alternating with voraciousness, diarrhea and constipation, colicky pains 
and abdominal qualms, nausea, salivation and intestinal indigestion. 
Debility, mental unrest, irritability and emaciation, pruritus of nose, 
anus or skin, disturbances of vision, tinnitus, choreic manifestations, and 
convulsions are with some doubt attributed to the presence of the worms. 
In one of the writer's cases homicidal mania was present, and disap- 
peared with the expulsion of the parasite. But it is impossible to sep- 
arate the symptoms really directly due to the worm from those that are 
wholly subjective. 

The diagnosis is made by the presence of the segments in the stools. 
They might possibly be confused with flakes of onion or mucous casts, 
but it is difficult to conceive how. When the segments are not passed 
the eggs may be detected. The prognosis is good. 

TreBtment: — Prophylaxis consists in eating wholesome meats, well 
cooked. Use pure water for drinking. Keep domestic animals in their 
place, and keep an eye on their health, and if possible have their stools 
watched. Cats may leave the little white sandlike eggs on cushions 
where they rest. 

For at least two days keep the patient on a diet of bread, milk and 
light soups, with saline laxatives; after the feces have been completely 
removed, instruct the patient to take no breakfast, and during the morn- 



TAPEWORM 807 

ing give the tenicide selected. In three hours follow with a brisk cathar- 
tic, and when the bowels begin to move have the patient sit on a jar of 
water that this may float the worm up and prevent the slender neck 
breaking off, leaving the head to develop anew. If the head is not found 
we must wait three months, when if it has retained life the segments will be 
ripe and appear in the stools. As a rule, if the larger part of the neck 
comes away, the death of the head will follow. Note that there may 
be more than one worm present. 

The writer has succeeded with oil of male fern, the seeds of the 
pumpkin, and oil of turpentine in doses of one or two ounces; but never 
with kousso or pomegranate. He has failed with all remedies when not 
administered in good quality and according to the above system. He 
prefers male fern for adults, and pumpkin seed, in doses of an ounce of 
the dried seeds, for little children. In the seeds the tenicide principle 
is contained in the greenish film surrounding the kernel, and as the latter 
contains a fixed oil which is laxative, the two may be given together, 
being simply fed to the child as shelled, like nut kernels. Kousso is 
abortifacient and unsafe for pregnant women. The addition of chloro- 
form renders any tenicide more effective. The adult dose of oil of male 
fern is half to one dram. Thymol, pelletierine and kameela have teni- 
cide powers. 

How should we determine the dose for children? If as usually 
assumed, tenicides act directly as poisons to the worm, it seems that the 
same dose should be required to kill a worm in an infant as in an adult. 
This has been denied, and some claim that the dose may be regulated 
by the age or weight as with drugs acting distinctly on the patient. The 
subject is not mentioned in any recent text-book on Practice. 

Overdoses of male fern are toxic and have even caused death. 
Struempell cautions against exceeding doses of two to three drams, and 
French advises against castor oil as rendering the toxic principles soluble. 

In Abyssinia where the practice of eating raw beef renders the entire 
population subject to tenia, kousso is employed as a corrective, an inti- 
mation to the worm that better behavior is expected of it, but not as a 
means of destroying its life. Other remedies are used for this latter 
purpose which have not been introduced into civilized lands. 

The patient may require tonics after the evacuation of the worm, 
especially iron which seems distasteful to all intestinal parasites. 

Tenia nana is a miniature tapeworm, less than an inch in length, 
believed to be a cause of epilepsy and enuresis nocturna, in children. 
This and other forms of tenia sometimes found in man are amenable 
to the same treatment as above described. 



So8 PEDICULOSIS: PHTHEIRIASIS 

SPIDERS (ARACHNIDS) 

Pentastoma tenioides inhabits the nasal passages of the dog or horse, 
sometimes attacking man, the ova being discharged by sneezing. Larvae 
have been found in the lungs, liver and kidneys. 

The Acarus Scabiei gives rise to the itch. The female is about 1-50 
inch in length and breadth, the male half these dimensions. They pierce 
the skin, residing in a burrow or cuniculus, in the end of which may be 
found the female with eggs. The lesions visible are mainly due to 
scratching. The parasites are easily killed but reproduce from some 
left in the clothing. Any ointment of sulphur, mercury, naphthol or 
phenol, will destroy them — especially one of copper oleate, 1 part to 16. 
The patient should take a hot bath with antiseptic soap, having all 
clothing put to soak in a tub of chloride of lime solution, and have clean 
clothing ready for next morning, the bath being taken on retiring. The 
ointment should be well rubbed into the affected parts, between the heads 
of the metacarpal bones on the backs of the hands, and at the flexures of 
elbows and knees, and not washed off till next morning. One thorough 
application will succeed where many partial ones fail. Probably satu- 
ration with caleium sulphide would destroy the parasites as quickly and 
more surely. 

Other acari infesting domestic animals invade the human skin but 
die promptly, the human serum being toxic to them. 

Leptus Autumnalis, the harvest bug or chigger of the north, redbug 
of the south, is a minute animal with six legs, claws and sharp man- 
dibles. It inhabits grass, and invades the ankles and legs of those who 
walk over infested patches. It appears as a minute red dot surrounded 
by the white urticarial zone of irritation it causes. Intense itching en- 
sues. The speediest relief follows touching the bug with choloroform, 
which instantly kills the parasite. The ointments employed for itch 
also are effective. 

Demodex folliculorum, a small parasite found in acne follicles, is not 
known to arouse symptoms or do harm 

PEDICULOSIS: PHTHEIRIASIS 

Three forms of lice infest man — the pediculus capitis, corporis and 
pubis. The headlouse is about 1-25 inch long, gray, with six legs, 
the female double the size of the male. She lays about 50 to 80 eggs in 
a week, in a bag attached to the hair near the skin. These "nits" hatch 
in three to eight days. They cause itching and an eruption about the 



PEDICULOSIS: PHTHEIRIASIS 809 

neck and ears. The term plica polonica was used to designate cases 
where the hair was matted with dirt and crusts and supposed to 
contain bloodvessels. 

Body lice infest the clothing. They are much larger than head lice, 
and deposit their ova on the clothing. Small hemorrhagic dots show 
where they have sucked blood through the sweat pores. Neglected 
cases show white scars from scratches, with scaly pigmented patches 
— "vagabonds" disease. 

Crab lice infest the pubis, axilla, eyelashes and brows, chest, and 
beard. 

All lice are killed by saturating the infected parts with kerosene oil 
and leaving it for a night. The application must be renew r ed in a few 
days to catch the newly hatched broods. The clothing should be boiled. 
All mercurial and naphthol ointments kill lice. Shoemaker advises 
betanaphthol a dram, in four ounces of cologne water. Tincture of 
cocculus is effective but not always safe from picrotoxin poisoning. 

Bedbugs are to be gotten rid of by sulphur fumigation, and appli- 
cations of corrosive sublimate solutions to their dwellings. Alkaline 
lotions or a drop of chloroform relieve their irritation. 

Fleas are especially averse to phenol, and may be kept away by drop- 
ping bits of blotting paper, wet with it, around the body in bed; or by 
spraying the carpet with it. 

The sand flea or jigger of the south penetrates the skin of the feet 
to lay her eggs, which appear as a bluish spot about the toenails, with 
itching. If the embryos escape great irritation and septi-c ulceration 
follow. People should wear shoes and stockings, and apply to the feet 
antiseptic powders impregnated with essential oils to escape this annoy- 
ance. 

Ticks will loosen their hold if a drop of any essential oil or of chloro- 
form is applied. 

Bird and fowl ticks or mites attack men and cause itching. Gnats, 
mosquitos, bot-flies, and several varieties of flies, attack man and annoy 
by their stings and by depositing their eggs in his tissues. The larvae 
of bot-flies have been found by French apparently causing epilepsy by 
their presence in the alimentary canal. Several flies deposit eggs that 
develop into maggots. Some caterpillars cause urticaria, especially one 
that has recently infested New England, the brown-tailed moth. 

The part played by these and other insects in spreading disease to 
man is just beginning to be comprehended. Typhoid fever, cholera, 
plague, tuberculosis, diphtheria, yellow fever and malaria, have been 
positively traced to the intervention of insects, and the possibilities in 



810 PEDICULOSIS: PHTHEIRIASIS 

this line are by no means exhausted. It is well therefore to wage an 
unceasing warfare on all insect pests, and to use every means of excluding 
them from our homes and persons. Sulphur fumigation will drive out 
everything from the rat to the micrococcus. Suitable means should be 
employed to keep them out. Probably saturation with sulphides renders 
one immune against all biting insects, and probably all others. Few 
of them will attack a surface of skin that is covered with any volatile 
oil, such as the citronella used at the seaside resorts. This may be se- 
cured from too speedy evaporation by incorporating it in soap, the lather 
applied being allowed to dry on the skin. Solutions of calcium sulphide 
applied to the exposed skin are found to keep off the voracious mosqui- 
toes of Alaska. The usual strength is 18 grains of chemically pure 
sulphide to one ounce of glycerin and two of water. This will enable 
the physician to walk unharmed through an epidemic of yellow fever 
or by night in malarial swamps with impunity. 

It is better to take calcium sulphide internally until the skin ex- 
hales ^he odor of the drug, when one is immune against all insects. 
Saturation may be sustained indefinitely without injury. 



INDEX 



INDEX 



A 

Abbott's Defervescent Triad 8 

Abscess, Pulmonary 319 

Acarus Scabiei 808 

Acetone, Test for 641 

Acetonuria 641 

Achlorhydria 520 

Achylia Gastrica 490 

Acroparesthesia 73 <> ~73 1 

Actinomycosis 199 

Acute Alcoholism 753 

Aortitis, see Aortitis. 
Endocarditis, see Endocarditis . . 
Myocarditis, sec Myocarditis. 

Pericarditis, see Pericarditis 355 

Phthisis 193 

Tuberculosis 191 

Addison's Disease 267 

Adenitis 190 

Adiposis Dolorosa 718-731 

Agraphia 694 

Ainhum 73°~73 1 

Albumin, Test for 640 

Albuminuria 640 

Cyclic 640 

Alcoholic Coma 753 

Dementia 755 

Intoxicants, Various 760 

Alcoholism 753 

Acute 757 

Chronic 754 

Diagnosis 756 

Etiology 753 

Pathology 753 

Symptoms 754 

Treatment 757 

Alexia 694 

Alkaloids, Putrefactive 779 

Amebic Dysentery 73—78 

Amyloid Liver, see Liver. 

Anemia 253 

Pernicious 255 

Diagnosis 257 

Etiology 256 

Symptoms 256 

Treatment 258 

Simple 253 

Treatment 254 

Aneurism of Ascending Aorta 441 

of Descending Aorta 442 

of Thoracic Aorta 439 

of Transverse Aorta 441 



Angina Ludovici 454 

Pectoris 422 

Angioneurotic Edema 725—731 

Anguillula Stercoralis 802 

Ankylostomum 795 

Anopheles and Malaria 51 

Anorexia 513 

Anthrax 200 

Antitoxin, Diphtheria 125 

Aorta, Ascending, Aneurism 441 

Thoracic, Aneurism 439 

Aortic Leak 383 

Anatomy 383 

Diagnosis 385 

Etiology 383 

Symptoms 384 

Stenosis 386 

Aortitis, Acute 436 

Aphasia 693 

Aphemia 693 

Aphthae 448 

Aphthous Stomatitis, see Stomatitis. 

Apoplexy 695 

Pulmonary 310 

Appendicitis 538 

Chronic 542 

Diagnosis 541 

Etiology 539 

Symptoms 540 

Appetite, Excessive 514 

Loss of 513 

Apraxia 694 

Arachnids 808 

Arsenic Poisoning 776 

Sulphide 4 

Arteries, Diseases of 432 

Inflammation of 437 

Syphilitic 438 

Arteriosclerosis 432 

Diagnosis 434 

Etiology 432 

Symptoms 433 

Treatment 435 

Arthritic Muscular Atrophy 749 

Arthritis Deformans 235 

Ascariasis 793 

Ascaris Lumbricoides 793 

Ascending Paralysis — see Paralysis. 

Ascites 598 

Asthenic Bulbar Paralysis 751 

Asthma 297 

Cardiac 418 



814 



INDEX 



Ataxia, Cerebrellar 678 

Friedreich's 678 

Locomotor 685 

Atelectasis 315 

Atrophy, Arthritic Muscular 749 

of Heart, see Heart. 

Neural Muscular, Progressive .... 746 

Spinal Muscular, Progressive .... 745 

Autointoxication 217 

Autotoxemia, Fecal 220 

B 

Bladder, Catarrh 630 

Diseases of 628 

Tuberculosis 633 

Bleeder's Disease 249 

Blood, Diseases of 253 

Fluke 792 

Body-louse 809 

Bothriocephalus Latus 806 

Bots 809 

Bednar's Aphthae 448 

Beri-beri 209 

Bernhardt's Disturbance 731 

Biernacki's Symptom 687 

Bilhartzia Haematobia 792 

Bradycardia 420 

Brain, Diseases of. 690 

Inflammation 698 

Malformations 694 

Tumor 699 

Brickdust Sediment •'. 650 

Bright's Disease 653-656-658 

Bronchial Diseases 286 

Stenosis 297 

Bronchiectasis 295 

Bronchitis, Acute 286 

Complicating Infectious Diseases. 156 

Chronic 290 

Etiology 290 

Symptoms 291 

Treatment 292 

Fibrinous 303 

in Measles 157 

Bronchopneumonia 311 

Bubonic Plague 105 

Buhl's Disease 251 

Bulbar Paralysis, see Paralysis. 

Bulimia 514 

Burggraeve's Defervescent .Triad 8 

c 

Cachexia, Malarial 59 

Strumipriva 275 

Caisson Disease 676 

Calcium Sulphide 4 

Sulphide in Diphtheria 124 

in Diphtheria 1 24 

in Measles 155-156 

in Scarlatina 152 

in Whooping Cough 160 



Calx Sulphurata in Malaria 67 

Camp Treatment of Pulmonary Dis- 
eases 335 

Cancer, Gastric 502 

Pericardial 369 

Pulmonary 320 

Carcinoma, Esophageal 463 

Gastric 502 

Intestinal 548 

Cardia, Insufficiency 510 

Cardiac Asthma, see Asthma 418 

Diseases 369 

Thrombus 427 

Cardiospasm 507 

Catarrh, Laryngeal, Acute 281 

Celiac Disease 535 

Cerebral Anemia 702 

Congestion 702 

Edema 702 

Embolism 702 

Hyperemia 701 

Maladies, Minor 701 

Cerebrospinal Fever 91 

Diagnosis 93 

Treatment 94 

Chancre 177 

Cheyne-Stokes Respiration 419 

Chickenpox 145 

Chigger 808 

Chlorine Water 3 

Chloroform Habit \ . . 761 

Chloroma 267 

Chlorosis 254 

Cholangitis 566 

Cholecystitis 568 

Cholera 80 

Infantum 528 

Morbus 536 

Nostras * ■ 536 

Treatment 84 

Cholerine 83 

Chorea 708-73 1 

Habit 710-731 

Hereditary . 710-731 

Chronic Dysentery 79 

If Endocarditis, see Endocarditis. 
W Myocarditis, see Myocarditis. 
f Pericarditis, see Pericarditis. 

Phthisis 321 

Pleurisy 351 

Pneumonia 314 

Chyluria 645 

Circulatory Equilibrium 6 

System, Diseases of 355 

Cirrhosis of Liver, see Liver. 

Cities, Malaria of 71 

Cocaine Habit 761 

Colitis, Mucous 554 

Etiology 554 

Symptoms 556 

Treatment 557 



INDEX 



815 



Colon, Dilatation 553 

Coma, Uremic 638 

Combined Valvular Lesions 393 

Comedone 808 

Compensation, Broken, Treatment. 406 

Imperfect, Treatment 400 

Congestion, Pulmonary 305 

Constipation 549 

Treatment 552 

Constitutional Diseases 217 

Consumption, Pulmonary, see Phthisis. 

Convulsions, Infantile 719-731 

Convulsive Tic 71 1-73 1 

Cor Bovinum 383 

Coryza, Acute 277 

Chronic 279 

Crab-louse 809 

Cranial Nerves, see Nerves. 

Cretinism 275 

Croup, Membranous 283 

Spasmodic 282 

Cyclic Albuminuria 640 

Cystitis, Acute 628 

Chronic 630 

Cytoryctes Variolar 131 

D 

Defervescent Triad in Fever 7 

Delirium Tremens 753 _ 757 

Delirious Mania, see Mania. 

Dementia Paralytica 700 

Demodex Folliculorum 808 

Dengue 103 

Descending Aortis, Aneurism 442 

Desquamative Nephritis, see Nephritis. 

Dextrocardia 427 

Diabetes, Diet 227 

Insipidus 234 

Mellitus 221 

Diagnosis 225 

Etiology 222 

Pathology 221 

Prognosis 225 

Prophylaxis 225 

Symptoms 223 

Treatment 226 

Diarrhea, Acute Dyspeptic 533 

Alba (Chylosa) 535 

Infantile 532 

Nervous 562 

Dietary Tables, Diabetic 230 

Diffuse Scleroderma 728-731 

Digestive System, Diseases of 447 

Dilatation, Heart, see Heart. 

Diphtheria 116 

Anatomy 118 

Antitoxin 125 

Bacilli of 117 

Calcium Sulphide in ; , 124 

Diagnosis 121 

Prophylaxis 121 



Diphtheria Symptoms 119 

Treatment 122 

Dipsomania 753 

Distomiasis 79 1 

Drug Habits 753 

Drunkenness 753 

Dry Pleurisy 344 

Ductless Glands, Diseases of 253 

Duodenum, Ulcers of 537 

Dysentery 72 

Amebic 73—78 

Catarrhal 74 

Chronic 79 

Diagnosis 75 

Prophylaxis 75 

Treatment 76 

Dyslexia 694 

Dyspepsia 466 

Nervous 506 

Dysphagia 464 

Dystrophy, Progressive Muscular. . . 748 

E 

Echinacea 3 

Echinococcus 803 

Echinol 3 

Edema, Angioneurotic 7 2 5~73 l 

Pulmonary 306 

Ehrlich's Diazo Reaction 27 

Embolism, Cerebral 702 

Pulmonary 311 

Emphysema 316 

Empyema 305 

Encephalitis 698 

Endocarditis, Acute 369 

Etiology 370 

Symptoms 370 

Treatment 373 

Chronic 374 

Obliterans 438 

Ulcerative 371 

Enteralgia 561 

Enteritis 521 

Infantile 532 

Phlegmonous 535 

Enteroliths 544 

Enterospasm 563 

Ephemeral Fever 13 

Epidemic Hemoglobinuria 250 

Epilepsy 71 1-73 1 

Epistaxis 280 

Erb's Sign 719 

Erysipelas 113 

Jaborandi in 114 

Eructation, Nervous 508 

Erythromelalgia 73°~73 T 

Esophagismus 464 

Esophagitis , — 462 

Esophagus, Carcinoma of 463 

Catarrh of 462 

Dilatation 464 



8i6 



INDEX 



Esophagus, Diseases of 462 

Stricture of 463-464 

Ether as an Intoxicant 760 

Eustrongylus Gigas 802 

Exophthalmic Goitre 271 

Diagnosis 272 

Etiology 271 

Treatment 273 

External Pachymeningitis, see Pachy- 
meningitis. 

F 

Facial Hemiatrophy 728-731 

Fatty Heart 416 

Liver, see Liver. 

Fecal Autotoxemia 220 

Fever 1 

Basal Prescription for 7 

Defervescent Triad in 7 

McCall Anderson's Treatment ... 9 

Management of 1 

Mediterranean 207 

Fibrinous Bronchitis, see Bronchitis. 
Pericarditis, see Pericarditis. 

Filaria Medinensis 802 

Sanguinis 799 

Varieties of 802 

Filariasis 799 

Floating Liver, see Liver. 
Kidney, see Kidney. 

Fluke 791 

Foot and Mouth Disease 213 

French Measles j . . 158 

Friedreich's Ataxia 678 

Fuller's Alkaline Treatment 130 

G 

Gall-stones 569 

Diagnosis 573 

Symptoms -. 570 

Treatment 574 

Gangrene of Mouth 451 

Pulmonary 318 

Gastralgia 512 

Gasterectasis 468-481 

Gastric, see also Stomach. 

Diseases 466 

Juice, Hydrochloric Acid Content 472 

Gastritis, Acid 489-514 

Phlegmonous 487 

Toxic 487 

Gastrodynia 512 

Gastroptosis 468-479 

Gastrospasm 507 

Gastrosuccorrhea 516 

Gastroxynsis 516 

Geni to-urinary System, Diseases of. 603 

German Measles 158 

Glossitis, Acute 453 

Chronic 454 

Desiccans 454 



Gleet 611 

Glanders 198 

Glandular Fever 214 

Goitre, Exophthalmic 271 

Gonorrhea, see also Urethritis. 

Acute 603 

Chronic 611 

Diagnosis 605 

Treatment 606 

Urine Examination 604 

Gout 236 

Diagnosis 238 

Symptoms 237 

Treatment 239 

Grand Mai 712-731 

Grippe 97 

Guinea-worm 802 

H 

Habit Chorea 710-731 

Haffkine's Anticholera Serum 81 

Hay Fever 279 

Headache 664 

Head-louse * . . 808 

Heart, Atrophy 426 

Dilatation 413 

Diseases of 369 

Fatty 416 

Hypertrophy 411 

Imperfections, Congenital 428 

Neuroses 428 

Palpitation .\ . 428 

Thrombus of 427 

Transposed . 427 

Heat Prostration 786 

Heller's Test 641-643 

Helmenthiasis 793 

Hematemesis 506 

Hematuria 641 

Hemiatrophy, Facial, Progressive. 728-731 

Hemoglobinuria 644 

Epidemic 250 

Hemoglobinuric Fever 56 

Hemopericardium 367 

Hemophilia 249 

Hemoptysis 307 

Hemorrhages of Infants 251 

Henoch's Purpura 248 

Hepatic, see Liver. 

Hepatitis, Acute 577 

Herpes Zoster 672 

Hodgkin's Disease 264 

Hook-worm 795 

Hydatids 321 

Hydrocephalus 692 

Hydromyelia 680 

Hydropericardium 366 

Hydrophobia 201 

Hydrothorax 354 

Hyperchlorhydria 472-514 

Hyperemia, Pulmonary 304 



INDEX 



*i7 



Hyperorexia 514 

Hyperpyrexia 9 

Hypertrophy of Heart, see Heart. 

Hypochlorhydria 472-518 

Hysteria 715—731 

Traumatic 71 6-73 1 

I 

Infantile Convulsions 719—73 r 

Pseudoleukemia Anemia 266 

Scurvy 247 

Infectious Cholangitis 546 

Myositis, see Myositis. 

Influenza 97 

Insolation 786 

Insomnia 7°5 - 73 I 

Intestinal Antiseptics 477 

Diseases, General Considerations. 520 

Sepsis 4 

Intestines, Catarrh 521 

Acute 522 

Pathology 522 

Symptoms 523 

Treatment 524 

Chronic 525 

Symptoms 525 

Treatment 527 

Carcinoma 548 

Diseases of 520 

Neuralgia of 561 

Obstruction of 544 

Diagnosis 546 

Symptoms 545 

Treatment 547 

Spasm of 563 

Ulcers of 537 

Interstitial Nephritis, see Nephritis. 

Intoxication, Ptomaine 778 

Intoxications 753 

Intussusception 544 

Itch 808 

J 

Jaborandi in Erysipelas 114 

Jacksonian Epilepsy 792 

Jaundice 564 

Catarrhal 565 

Jigger 808 

K 

Kernig's Sign 692 

Kidney, Floating 635 

Movable 635 

Kidneys, Congestion 636 

Passive 637 

Diseases of 635 

Displaced 635 

Hyperemia 636 

Klebs-Loeffler Bacillus 116 



L 

Landry's Paralysis 673 

Laryngeal Catarrh, Acute 28] 

Laryngismus Stridulus 282 

Laryngitis. Chronic 282 

Larynx, Diseases of 281 

Edema of 283 

Lateral Sclerosis, see Sclerosis. 

Lead Poisoning 773 

Leprosy [85 

Leptomeningitis 675-690 

Cerebral 692 

Leucoplakia Oris 454 

Leukemia 261 

Symptoms 262 

Treatment 264 

Leyden's Muscular Paralysis 749 

Lice 808 

Liege und Dauerluftkur 338 

Lithemia 240-650 

Lithiasis 650 

Lithuria 650 

Liver, Abscess 577 

Adenoma • 582 

Amyloid _ 585 

Atrophy, Acute 577 

Carcinoma 582 

Cirrhosis 578 

Hypertrophic 582 

Pathology 578 

Symptoms 579 

Treatment 580 

Diseases of 563 

Fatty 584 

Floating 563 

Fluke 791 

Hyperemia 576 

Neoplasms 582 

Neuralgia of 586 

Parasites in 583 

Pigmented 586 

Sarcoma 582 

Locomotor Ataxia 685 

Diagnosis 688 

Treatment 680 

LoefHer's Solution 1 23 

Luftkur 338 

Lumpy-jaw 1 99 

Lungs, Diseases of 304 

M 

Malaria 46 

Acclimatization 61 

Anatomy 57 

Calx Sulphurata in 67 

Diagnosis 61 

Enlarged Spleen of 70 

Etiology 60 

Hemoglobinuria in 65 

Larval Forms 70 



INDEX 



Malaria of Cities 71 

Parasite 47 

Treatment 63 

Malarial Cachexia 59 

"Yellow Fever" 69 

Malformations of Brain 694 

Malta Fever 207 

Management of the Predisposed 340 

Mania-a-potu 753 

Mania, Delirious, Acute 703 

Measles 153 

Bronchitis Complication 156 

Calcium Sulphide in 155-156 

Diagnosis 154 

Treatment 154 

Mediterranean Fever 207 

Medulla, see also Spine. 

Anemia 679 

Dilatation 680 

Hemorrhage 679 

Hyperemia 679 

Membranous Croup 283 

Stomatitis, see Stomatitis. 

Meniere's Disease 665 

Meninges, Diseases of 690 

Meningitis 690 

Tubercular 192 

Meningocele , 694 

Meralgia Paresthetica. 731 

Mercurial Poisoning 777 

Ptyalism 452 

Merycism 510 

Metabolism, Acid Products of ... 217 

Migraine 664 

Milk Disease 212 

Mitral Insufficiency, Relative 415 

Leak (Insufficiency, Regurgita- 
tion) 376 

Diagnosis 380 

Pathology 376 

Symptoms 377 

Stenosis 381 

Morbus Maculosus Neonatorum .. . 251 

Morphine Habit 763 

Effects 765 

Treatment 770 

Morphcea 729-731 

Morton's Metatarsalgia 672 

Mosquito and Malaria 51 

Mountain Fever 42 

Mouth, Diseases of 447 

Gangrene of 45 1 

Mucous Colitis, see Colitis. 

Multiple Neuritis 668 

Mumps 165 

Muscarine 780 

Muscles, Diseases of 745 

Mushroom Poisoning 780 

Myasthenia Gravis 751 

Myelitis 683 

Myocardial Tumors 426 



Myocarditis, Acute 408 

Chronic 409 

Myocardium, Syphilis of 425 

Myositis, Infectious 745 

Myotonia 750 

Mytilotoxin 779 

Myxedema 274 

N 

Narcomania 763 

Nephritis, Desquamative, Acute 653 

Chronic 656 

Interstitial, Chronic 658 

Nephroptosis 635 

Nerve Disorders, Treatment in Gen- 
eral 731 

Tumors 671 

Nerves, Peripheral, Diseases of ... . 661 

Cranial, Diseases of 666 

Inflammation^ of 668 

Neurasthenia 720-731 

Nervous Diarrhea, see Diarrhea. 

Prostration 720-731 

Syphilis 699 

System, Diseases of 661 

Neural Muscular Atrophy, Progres- 
sive 746 

Neuralgia 661 

Etiology 661 

Intestinal, see Intestine. 
Neuritis ,. , 668 

Sciatic 670 

Neuroses, see Nerves. 

Cardiac, see Heart. 

Gastric 506 

Stomach, Irritative Motor, Treat- 
ment 508 

Treatment in General 731 

Noma , 451 

Nose-bleed 280 

Nose, Diseases of 277 

Nuclein 4 

Nutrition, Disorders of 725—731 

o 

Obesity 781 

Opium Habit, see Morphine. 

Oxaluria 646 

Oxyuris Vermicularis 794 

P 

Pachymeningitis 675-690 

Hemorrhagic 691 

Palpitation of Heart 428 

Pancreatitis, Acute 592 

Chronic 592 

Pancreas, Calculus of 593 

Carcinoma of 592 

Cysts of 593 

Diseases of 591 



INDEX 



819 



Pancreas, Fat-necrosis of 592 

Hemorrhage 59 1 

Paralysis Agitans 'l '] - !^ 1 

Ascending, Acute 673 

Asthenic Bulbar 75 1 

Bulbar 682 

Glosso-labio-pharyngeal 682 

Hypertrophic Muscular 747 

Landry's 673 

of Children 704 

of Insane 700 

Postdiphtheritic 126 

Pseudobulbar 682 

Paralytic Dementia 700 

Paraphlegia, Spastic 678 

Paraplexia 694 

Parasites, Animal 791 

Paratyphoid Fever 40 

Paresis 700 

Parkinson's Disease 707 

Pediculosis 808 

Peliosis Rheumatica 248 

Pentastoma Tenioides 808 

Pernicious Anemia 255 

Pericardial Cancer, see Cancer. 
Syphilis, see Syphilis. 
Tuberculosis, see Tuberculosis. 

Pericarditis, Acute, Anatomy 355 

Etiology 356 

Chronic 364 

Treatment 366 

Fibrinous, Diagnosis 358 

Symptoms 357 

Effusional 359 

Diagnosis 360 

Symptoms 359 

Treatment 362 

Pericardium, Diseases of 355 

Periencephalitis 703 

Perihepatitis 576 

Peristaltic Unrest 507 

Peritoneum, Diseases of 594 

Neoplasms of 600 

Peritonitis, Acute 594 

Chronic 597 

Localized 595 

Pfeiffer's Bacillus 97 

Phallin 781 

Pharyngitis, Acute 460 

Chronic 461 

Pharynx, Diseases of 460 

Phosphaturia 648 

Phtheiriasis 808 

Phthisis, Acute 195 

Chronic 321 

Camp and Sanatorium Treat- 
ment 335 

Diagnosis 326 

Liability 326 

Management of Predisposed. . . 340 



Phthisis, Chronic, Pathology 321 

Prognosis 326 

Symptoms 322 

Treatment 327 

Prophylaxis 340 

Pin-worm 7Q4 

Phlegmonous Enteritis, see Enteritis. 

Pleurisy 344 

Chronic 351 

D] 7 344 

Serous 346 

Diagnosis 348 

Symptoms 346 

Treatment 349 

Plumbism, see Lead. 

Plague 105 

Diagnosis 109 

Pathology 108 

Prophylaxis no 

Symptoms 106 

Treatment in 

Plasmodium Malaria? 47 

Pleuropneumonia 100 

Pneumonia 167 

Applications to Chest 174 

Complications 171 

Chronic 314 

Etiology 167 

Diagnosis 172 

Prognosis 1 73 

Symptoms 1 69 

Treatment 173 

Varieties 172 

Pneumonokoniosis 319 

Pneumopericardium 368 

Pneumothorax 352 

Poisoning, Chronic 753 

from Decayed Foods 779 

Polioencephalitis 698 

Poliomyelitis, Anterior, Acute 681 

Portal Vein, Diseases of 587 

Progressive Facial Hemiatrophy. 728-731 

Muscular Dystrophy 748 

Neural Muscular Atrophy 746 

Spinal Muscular Atrophy 746 

Prostate, Diseases of 622 

Hyperemia 623 

Hyperesthesia of 622 

Neuralgia of 622 

Prostatitis, Acute 625 

Prostatorrhea 624 

Pseudoangina 429 

Pseudobulbar Paralysis, see Paralysis. 

Pseudohypertrophic Muscular 

Atrophy 747 

Pseudoleukemia 264 

Infantile 266 

Secondary 259 

Splenic 267 

Symptomatic. 259 



820 



INDEX 



Pseudo -Whooping Cough 164 

Psilosis 536 

Psorospermiasis 79 1 

Psychophore 644 

Ptomaine Poisoning 778 

Ptyalism, Mercurial 452 

Pulmonary Abscess 319 

Apoplexy 310 

Cancer 320 

Congestion 305 

Diseases 304 

Camp Sanatorium Treatment. 335 

Edema 306 

Embolism 311 

Gangrene 318 

Hyperemia 304 

Leak 390 

Stenosis 391 

Purpura Simplex 247 

Hagmorrhagica 248 

Pyelitis 634 

Pyelonephritis 634 

Pylephlebitis 588 

Pylorospasm 508 

Pylorus, Insufficiency 510 

Pyonephrosis 634 

Pyuria 646 

Q 

Quincke's Disease 725-731 

Quinsy 457 

R 

Raynaud's Disease 726-731 

Reaction, Ehrlich's Diazo 27 

Reichmann's Disease 516 

Relapsing Fever 45 

Renal, see Kidney. 

Respiratory System, Diseases of . . . . 277 

Rheumatism 126 

Diagnosis 129 

Treatment 129 

Rhizomelique Spondylitis 672 

Rickets 242 

Diagnosis 243 

Symptoms 242 

Treatment 244 

Riga's Disease 448 

Robert's Test 641 

Rocky Mountain Spotted Fever 41 

Roetheln 154 

Romberg's Symptom 687 

Roseola 158 

Round-worm 793 

Rubella 158 

Rubeola 158 

Rumination 510 

Black Smallpox 134 

s 

St. Vitus' Dance, see Chorea. 

Saliva, Hypersecretion 455 



Salivary Glands, Diseases of... 453-455 

Salivation 453 

Saltatory Spasms 711-731 

Sand Flea 809 

Scarlet Rash 158 

Scarlatina 146 

Calcium Sulphide in 152 

Prophylaxis 152 

Symptoms 147 

Treatment 150 

Schoenlein's Disease 248 

Sciatica 664 

Sciatic Neuritis 670 

Secondary Anemia 259 

Sepsis, Intestinal 4 

Serous Pleurisy 346 

Sick-headache 664 

Simple Anemia 253 

Sleeping Sickness 803 

Sleeplessness 7°5~73 1 

Scleroderma, Circumscribed 729-731 

Diffuse 728-731 

Scleroses, Combined 683 

Sclerosis, Lateral, Primary 677 

Multiple 684 

Scurvy 245 

Infantile 247 

Smallpox 131 

Diagnosis 135 

Hemorrhagic 134 

Treatment 136 

Symptoms » * 132 

Spasmodic Croup 282 

Spastic Paraplegia ^ 678 

Spiders 808 

Spina Bifida 676 

Spinal, see also Medullary. 

Spinal Cord, Diseases of 675 

Inflammation 683 

Maladies : 679 

Membranes, see also Medullary. 

Membranes, Diseases of 675 

Muscular Atrophy, Progressive. . 745 

Spleen, Diseases of 588 

Dislocated 588 

Enlarged, of Malaria 70 

Abscess 590 

Atrophy 590 

Diseases of 588 

Hyperemia 589 

Rupture 589 

Splenic Anemia 267 

Splenomegaly 591 

Splenoptosis 588 

Splenitis, Acute 589 

Chronic 589 

Spondylitis 672 

Spotted Fever, Rocky Mountain.. 4 . 41 

Sprue ; 536 

Stenosis, Bronchial 297 

Stokes-Adams Disease 420 



INDEX 



821 



Stomach, Acidity, Absence 520 

Atony 510 

Cancer of 473-502 

Pathology 502 

Symptoms 503 

Treatment 505 

Catarrh, Acute 485 

Chronic 488 

Pathology 488 

Symptoms 489 

Treatment 492 

Contents, Examination 469 

Depressive States 510 

Dilated 468-481 

Diseases of 466 

Diagnosis 471 

Diet in 474 

General Considerations 466 

Intestinal Antiseptics in 477 

Symptoms 471 

Tube in 479 

Hemorrhage 472 

Hyperacidity 514 

Hyperesthesia 511 

Hypersecretion of 516 

Motility, Deficient 468 

Motor Neuroses 507 

Neuralgia 512 

Neuroses of 506 

Secretory 514 

Sensory 511 

Treatment, Medicinal 476 

Prolapsed 468-479 

Secretory Neuroses 514 

Sensory Neuroses 511 

Subacidity of 518 

Troubles, General Considerations 466 

Ulcer of 472-498 

Diagnosis 500 

Symptoms 499 

Treatment 501 

Stomatitis 447 

Aphthous 448 

Membranous 449 

Ulcerative 449 

Stricture, Esophageal 463 

Congenital L 618 

Organic 617 

Urethral 616 

Struempell's Polioencephalis 704 

Sulphocarbolates 6 

Summer Diarrhea 532 

Sunstroke 786 

Treatment 788 

Symptomatic Anemia 259 

Symptoms, Diagnosis 149 

Synoque 13 

Syphilis 176 

Anatomy 177 

Diagnosis 180 

Hereditary 1 78 



Syphilis of Internal Organs 179 

of Myocardium 425 

Nervous 699 

Pericardial 369 

Prophylaxis 181 

Treatment 182 

Syphilitic Arteries 438 

Syringomyelia 680 

T 

Tachycardia 43 1 

Tape-worm 803-804 

Tenia Nana 807 

Solium 805 

Varieties of '. . 806 

Test, Dimethylamidoazobenzol 515 

for Acetone 641 

for Albumin 640 

for Blood in Urine 641 

for Uric Acid 65 1 

Heller's 641-643 

Meal 469-515 

Robert's 64 1 

Toepfer's 515 

Tetanus 204 

Treatment 206 

Tetany 718-731 

Thread-worm 794 

Long 795 

Throat, Diseases of 281 

Thrombus, Cardiac 427 

Thrush 450 

Thyroid Gland, Inflammation 269 

Thyroiditis 269 

Tic, Convulsive 711-731 

Douloureux 662 

Ticks 809 

Toepfer's Test 515 

Tongue, Diseases of 453 

Tonsillectomy 459 

Tonsillitis, Acute 456 

Follicular 456 

Chronic 458 

Parenchymatous 457 

Tonsils, Diseases of 456 

Toxalbumins 779 

Toxalbumoses 779 

Toxines 779 

Toxine Poisoning 779 

Transverse Arch, Aneurism 441 

Tricuspid Leak 387 

Stenosis 388 

Trichina Spiralis 796 

Trichiniasis 796 

Trichocephalus Dispar 795 

Trophic Disorders 7 2 5~73 I 

Trypanosoma 803 

Trypanosomiasis 803 

Tubercular Meningitis 192 

Tuberculosis 187 

Etiology 187 



822 



INDEX 



Tuberculosis Pathology. 188 

Pericardial 368 

Pulmonary, see Phthisis. 

Varieties 196 

Tumors, Myocardial 426 

Tylosis Linguae 454 

Typhoid Fever 15 

Agglutination 29 

Bacillus 15 

Convalescence 34 

Diagnosis 29 

Prognosis 30 

Prophylaxis 31 

Treatment 32 

Typhus Fever 43 

Tyrotoxicon 779 

u 

Ulcerative Endocarditis, see Endo- 
carditis. 

Stomatitis, see Stomatitis. 

Ulcers, Intestinal 537 

Uncinaria Duodenale 795 

Uncinariasis 795 

Uremia 638 

Uremic Coma 638 

Urethra, Diseases of 603 

Stricture of 616 

Urethrismus . . 616 

Urethritis, Gonorrheal, Anterior — 603 

Posterior 609 

See also Gonorrhea. 

Urethrotomy ' 620 

Uricacidemia 650 

Uric-Acid Diathesis 650 

Test for 651 

Urine. Retention 62T 



V 

Vaccination 140 

Objections Answered 143 

Vaccinia 141 

Valvular Heart Lesions, Combined. 393 

Diagnostic Murmurs 392 

Prognosis 394 

Treatment 396 

Varicella 145 

Vasomotor Disorders 725—731 

Vertigo 704-731 

Volvulus 544 

Vomit, Blood 506 

Vomiting, Nervous 508 

w 

Weil's Disease 208 

Werlhof 's Disease 248 

Westphal's Sign 686 

Wet-pack 639 

Whip-worm 795 

Whooping Cough 158 

Calcium Sulphide in 160 

Prophylaxis 160 

Pseudo 164 

Symptoms 159 

Treatment 160 

Winckel's Disease 250 

Writer's Cramp. 717-731 

Yellow Fever 86 

Anatomy 87 

Diagnosis „ 88 

"Malarial" 69 

Symptoms 87 

Prophylaxis 89 

' Treatment 89 



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APR 13 190? 



